Chapter 4: Thoracic Trauma

Objectives:
Upon completion of this topic, the physician will be able to identify and initiate
treatment of life-threatening thoracic injuries.
Specifically, the physician will be able to:
A. Identify and manage the following immediately life-threatening chest injuries
evidenced in the primary survey:
1. Airway obstruction
2. Tension pneumothorax
3. Open pneumothorax
4. Massive hemothorax
5. Flail chest
6. Cardiac tamponade.
B. Identify and initiate treatment of the following potentially life-threatening injuries
assessed during the secondary survey:
1. Pulmonary contusion
2. Myocardial contusion
3. Aortic disruption
4. Traumatic diaphragmatic rupture
5. Tracheobronchial disruption
6. Esophageal disruption.
C. Explain the purpose of, define the complications of, and demonstrate the ability to
perform needle thoracocentesis, chest tube insertion, and pericardiocentesis in a surgical skill
practicum.

I. Introduction
A. Incidence
Chest injuries cause one of every four trauma deaths in North America. Many of these
patients die after reaching the hospital. Many of these deaths can be prevented by prompt
diagnosis and treatment coupled with an understanding of pathophysiologic factors associated
with thoracic trauma.
Because most injuries occur at a distance from a trauma center, recognition of the
features of thoracic injuries that require early intervention and influence transport is very
important. Less than 10% of blunt chest injuries require an operation, and 15% to 30% of
penetrating chest injuries require open thoracotomy. Most patients sustaining thoracic trauma
may be managed by simple procedures within the capabilities of any physician taking this
course. Therefore, the responsibility for the initial management of most chest-injury patients
rests with the physician who first examines the patient, and not the trauma surgeon to whom
the patient may be transferred.
B. Pathophysiology
Tissue hypoxia, hypercarbia, and acidosis often result from chest injuries. Tissue
hypoxia results from inadequate delivery of oxygen to the tissues because of hypovolemia
(blood loss), pulmonary ventilation/perfusion mismatch (contusion, hematoma, alveolar
collapse, etc), and changes in intrathoracic pressure relationships (tension pneumothorax, open
pneumothorax, etc). Hypercarbia implies hypoventilation. Acutely, hypoxia is more important.
Respiratory acidosis is caused by inadequate ventilation, changes in intrathoracic pressure
relationships, depressed level of consciousness, etc. Metabolic acidosis is caused by
hypoperfusion of the tissues (shock).
C. Initial Assessment and Management
1. Patient management must consist of:
a. Primary survey
b. Resuscitation of vital functions
c. Detailed secondary survey
d. Definitive care.
2. Because hypoxia is the most serious feature of chest injury, early interventions are
designed to ensure that an adequate amount of oxygen is delivered from the lung to the
tissues.
3. Immediately life-threatening injuries are treated as quickly and as simply as
possible.

4. Most life-threatening thoracic injuries are treated with an appropriately placed chest
tube or needle.
5. The secondary survey is guided by a high index of suspicion for specific injuries.
II. Primary Survey of Life-threatening Injuries
A. Airway
1. Assess for airway patency and air exchange by listening for airway movement at
the patient's nose and mouth.
2. Assess for intercostal and supraclavicular muscle retractions.
3. Assess the oropharynx for foreign body obstruction, particularly in the unconscious
patient.
B. Breathing
Expose the patient's chest completely and evaluate breathing. Assess respiratory
movement and quality of respiration by observing, palpating, and listening.
The signs of chest injury or hypoxia that are particularly important and often subtle
include an increased rate of breathing and a change in the breathing pattern, especially toward
progressively more shallow respirations. Cyanosis is a late sign of hypoxia in the trauma
patient. However, the absence of cyanosis does not indicate adequate tissue oxygenation or
an adequate airway.
c. Circulation
1. Assess the patient's pulse for quality, rate, and regularity. Remember, the radial and
dorsalis pedis pulses may be absent in the hypovolemic patient.
2. Assess the blood pressure for pulse pressure.
3. Observe and palpate the skin for color and temperature to assess the peripheral
circulation.
4. Check to see if the neck veins are distended. Remember, neck veins may not be
distended in hypovolemic patients with cardiac tamponade.
5. A cardiac monitor should be attached to the patient. Patients sustaining thoracic
trauma - especially in the area of the sternum or from a rapid deceleration injury - are
susceptible to myocardial contusion and/or coronary artery spasm, which may lead to
dysrhythmias. Hypoxia and/or acidosis enhance this possibility. Premature ventricular
contractions, a common dysrhythmia, may require treatment with an immediate lidocaine
bolus (1 mg/kg) followed by a lidocaine drip (2 to 4 mg/minute). Electromechanical
dissociation (EMD) is manifest by an electrocardiogram (ECG) showing a rhythm while the
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patient has no identifiable pulse. EMD may be present in cardiac tamponade, tension
pneumothorax, profound hypovolemia, or even worse, cardiac rupture.
D. Thoracotomy
Closed heart massage for cardiac arrest or EMD is ineffective for a hypovolemic
patient. Patients with exsanguinating, penetrating precordial injuries who arrive pulseless but
with myocardial electrical activity may be candidates for emergency department thoracotomy.
Assuming a surgeon is present, a left anterior thoracotomy, cross-clamping of the descending
thoracic aorta, pericardiotomy, and open chest massage in conjunction with intravascular
volume restoration may be initiated. Emergency department thoracotomy for patients with
blunt thoracic injuries, in whom there is no electrical cardiac activity, is rarely effective.
III. Life-threatening Chest Injuries Identified in the Primary Survey
A. Airway Obstruction
Airway obstruction at the alveolar level is a potentially life-threatening injury that is
assessed and managed during the secondary survey and definitive care phases. Chapter 2 deals
with the management of life-threatening situations of the upper airway.
B. Tension Pneumothorax
A tension pneumothorax develops when a "one-way-valve" air leak occurs either from
the lung or through the chest wall. Air is forced into the thoracic cavity without any means
of escape, completely collapsing the affected lung. The mediastinum and trachea are displaced
to the opposite side, decreasing venous return and compressing the opposite lung.
The most common causes of tension pneumothorax are mechanical ventilation with
positive end-expiratory pressure, spontaneous pneumothorax in which ruptured
emphysematous bullae have failed to seal, and blunt chest trauma in which a parenchymal
lung injury has failed to seal. Occasionally traumatic defects in the chest wall may cause a
tension pneumothorax. A significant incidence of pneumothorax is associated with subclavian
or internal jugular venous catheter insertion.
Tension pneumothorax is a clinical diagnosis and should not be made
radiologically. A tension pneumothorax is characterized by respiratory distress, tachycardia,
hypotension, tracheal deviation, unilateral absence of breath sounds, neck vein distention, and
cyanosis as a late manifestation. Because of the similarity in their symptomatology, a tension
pneumothorax initially may be confused with cardiac tamponade. However, a tension
pneumothorax is more common. Differentiation may be made by a hyperresonant percussion
note over the ipsilateral chest.
Tension pneumothorax requires immediate decompression and is managed initially
by rapidly inserting a needle into the second intercostal space in the midclavicular line of the
affected hemithorax. This maneuver converts the injury to a simple pneumothorax. (Note: The
possibility of subsequent pneumothorax as a result of the needle stick now exists.) Repeated
reassessment is necessary. Definitive treatment usually requires only the insertion of a chest
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tube into the fifth intercostal space (nipple level), anterior to the midaxillary line.
C. Open Pneumothorax ("Sucking Chest Wound")
Large defects of the chest wall, which remain open, result in an open pneumothorax
or sucking chest wound. Equilibration between intrathoracic pressure and atmospheric pressure
is immediate. If the opening in the chest wall is approximately two thirds the diameter of the
trachea, air passes preferentially through the chest defect with each respiratory effort, because
air tends to follow the path of least resistance through the large chest-wall defect. Effective
ventilation is thereby impaired, leading to hypoxia.
Manage an open pneumothorax by promptly closing the defect with a sterile occlusive
dressing, large enough to overlap the wound's edges, and taped securely on three sides.
Taping the occlusive dressing on three sides provides a flutter-type valve effect. As the patient
breathes in, the dressing is occlusively sucked over the wound, preventing air from entering.
When the patient exhales, the open end of the dressing allows air to escape. A chest tube
should be placed remote from the wound as soon as possible. Securely taping all edges of the
dressing can cause air to accumulate in the thoracic cavity resulting in a tension
pneumothorax unless a chest tube is in place. Any occlusive dressing (plastic wrap,
petrolatum gauze, etc) may be used as a stopgap so rapid assessment can continue. Definitive
surgical closure of the defect is usually required.
D. Massive Hemothorax
Massive hemothorax results from a rapid accumulation of more than 1500 mL of
blood in the chest cavity. It is most commonly caused by a penetrating wound that disrupts
the systemic or hilar vessels. It may also be the result of blunt trauma. The blood loss is
complicated by hypoxia. The neck veins may be flat secondary to severe hypovolemia or may
be distended because of the mechanical effect of intrathoracic blood. This condition is
discovered when shock is associated with the absence of breath sounds and/or dullness to
percussion on one side of the chest.
Massive hemothorax is initially managed by the simultaneous restoration of blood
volume and decompression of the chest cavity. Large-caliber intravenous lines and rapid
crystalloid infusion are begun and type-specific blood is administered as soon as possible. If
an auto-transfusion device is available, it may be used. A single chest tube (#38 French) is
inserted at the nipple level, anterior to the midaxillary line, and rapid restoration of volume
continues as decompression of the chest cavity is completed. When massive hemothorax is
suspected, prepare for autotransfusion. If 1500 mL is immediately evacuated, it is highly
likely that the patient will require an early thoracotomy.
Some patients who have an initial volume output of less than 1500 mL, but continue
to bleed, may require a thoracotomy. This decision is based on the rate of continuing blood
loss (200 mL/hour). During patient resuscitation, the volume of blood initially drained from
the chest tube and the rate of continuing blood loss must be factored into the amount of
intravenous fluid replacement. The color of the blood (arterial or venous) is a poor indicator
of the necessity for thoracotomy.

Penetrating anterior chest wounds medial to the nipple line and posterior wounds
medial to the scapula should alert the physician to the possible need for thoracotomy, because
of possible damage to the great vessels, hilar structures, and the heart, with the associated
potential for cardiac tamponade. Thoracotomy is not indicated unless a surgeon is present
and the procedure is performed by a physician qualified by training and experience.
E. Flail Chest
A flail chest occurs when a segment of the chest wall does not have bony continuity
with the rest of the thoracic cage. This condition usually results from trauma associated with
multiple rib fractures. The presence of a flail chest segment results in severe disruption of
normal chest wall movement. If the injury to the underlying lung is significant, serious
hypoxia may result. The major difficulty in flail chest stems from the injury to the underlying
lung. Although chest wall instability leads to paradoxical motion of the chest wall with
inspiration and expiration, this defect alone does not cause hypoxia. Associated pain with
restricted chest wall movement and underlying lung injury contribute to the patient's hypoxia.
Flail chest may not be apparent initially because of splinting of the chest wall. The
patient moves air poorly, and movement of the thorax is asymmetrical and uncoordinated.
Palpation of abnormal respiratory motion and crepitus of rib or cartilage fractures aids
diagnosis. A satisfactory chest roentgenogram may suggest multiple rib fractures, but may not
show costochondral separation. Arterial blood gases, suggesting respiratory failure with
hypoxia, also may aid in diagnosing a flail chest.
Initial therapy includes adequate ventilation, administration of humidified oxygen, and
fluid resuscitation. In absence of systemic hypotension, the administration of crystalloid
intravenous solutions should be carefully controlled to prevent overhydration. The injured lung
in a flail chest is sensitive to both underresuscitation of shock and fluid overload. Specific
measures to optimize fluid measurement must be taken for the patient with flail chest.
The definitive treatment is to re-expand the lung, ensure oxygenation as completely
as possible, administer fluids judiciously, and provide analgesia to improve ventilation. Some
patients can be managed without the use of a ventilator. However, prevention of hypoxia is
of paramount importance for the trauma patient, and a short period of intubation and
ventilation may be necessary until the diagnosis of the entire injury pattern is complete. A
careful assessment of the respiratory rate, arterial oxygen tension, and an estimate of the work
of breathing will indicate appropriate timing for intubation and ventilation. Not all patients
with a flail chest require immediate endotracheal intubation.
F. Cardiac Tamponade
Cardiac tamponade most commonly results from penetrating injuries. Blunt injury also
may cause the pericardium to fill with blood from the heart, great vessels, or pericardial
vessels. The human pericardial sac is a fixed fibrous structure, and only a relatively small
amount of blood is required to restrict cardiac activity and interfere with cardiac filling.
Removal of small amounts of blood or fluid, often as little as 15 mL to 20 mL, by
pericardiocentesis may result in immediate hemodynamic improvement.

The classic Beck's triad consists of venous pressure elevation, decline in arterial
pressure, and muffled heart sounds. However, muffled heart tones are difficult to assess in
the noisy emergency department. Distended neck veins, caused by the elevate central venous
pressure, may be absent due to hypovolemia. Pulsus paradoxus, a decrease in systolic pressure
during inspiration in excess of 10 mm Hg, also may be absent in some patients or difficult
to detect in some emergency settings. In addition, tension pneumothorax - particularly on the
left side - may mimic cardiac tamponade. Kussmaul's sign (a rise in venous pressure with
inspiration when breathing spontaneously) is a true paradoxical venous pressure abnormality
associated with tamponade. Electromechanical dissociation in the absence of hypovolemia and
tension pneumothorax suggests cardiac tamponade.
Pericardiocentesis is indicated for patients who do not respond to the usual measures
of resuscitation for hemorrhagic shock and who have the potential for cardiac tamponade.
Insertion of a central venous line may aid diagnosis. Life-saving pericardiocentesis should not
be delayed for this diagnostic adjunct. A high index of suspicion coupled with a patient who
is unresponsive to resuscitative efforts are all that is necessary to initiate pericardiocentesis
by the subxyphoid method.
Even though cardiac tamponade is strongly suspected, the initial administration of
intravenous fluid will raise the venous pressure and improve cardiac output transiently while
preparations are made for pericardiocentesis via the subxyphoid route. The use of a plasticsheathed needle is preferable, but the urgent priority is to aspirate blood from the pericardial
sac. Electrocardiographic monitoring may identify current of injury and needle-induced
dysrhythmias. Because of the self-sealing qualities of the myocardium, aspiration of
pericardial blood alone may relieve symptoms temporarily. However, all patients with positive
pericardiocentesis due to trauma will require open thoracotomy and inspection of the heart.
Pericardiocentesis may not be diagnostic or therapeutic because the blood in the pericardial
sac is clotted. Preparations for transfer of these patients to the appropriate facility is
necessary. Open pericardiotomy may be life-saving but is indicated only when a qualified
surgeon is available.
Once these injuries and other immediate, life-threatening injuries have been treated,
attention may be directed to the secondary survey and definitive care phase of potential, lifethreatening thoracic injuries.
IV. Potentially Lethal Chest Injuries Identified in the Secondary Survey
The secondary survey requires further in-depth physical examination, an upright chest
roentgenogram if the patient's condition permits, arterial blood gases, and an
electrocardiogram. In addition to lung expansion and the presence of fluid, the chest film
should be examined for widening of the mediastinum, a shift of the midline, or loss of
anatomic detail. Multiple rib fractures and fractures of the first and/or second rib(s) are
evidence of severe force delivered to the chest and underlying tissues.

Six potentially lethal injuries are considered herein:

1. Pulmonary contusion
2. Myocardial contusion
3. Aortic disruption
4. Traumatic diaphragmatic rupture
5. Tracheobronchial disruption
6. Esophageal disruption.
Unlike immediately life-threatening conditions, these injuries are not obvious on initial
physical examination. Diagnosis requires a high index of suspicion. All are more often
missed than diagnosed during the initial posttraumatic period. However, if these injuries are
overlooked, lives may be lost.
A. Pulmonary Contusion With or Without Flail Chest
Pulmonary contusion is the most common potentially lethal chest injury seen in North
America. The respiratory failure may be subtle and develops over time rather than occurring
instantaneously. The plan for definitive management may change with time warranting careful
monitoring and re-evaluation of the patient.
Some patients with stable conditions may be managed selectively without endotracheal
intubation or mechanical ventilation. Patients with significant hypoxia should be intubated and
ventilated within the first hour after injury. Associated medical conditions, eg, chronic
pulmonary disease and renal failure, predispose to the need for early intubation and
mechanical ventilation.
If the patient cannot maintain satisfactory oxygenation or has any of the above
complicating features, intubation and mechanical ventilation should be considered. Pulse
oximetry, ABG determination, ECG monitoring, and appropriate ventilatory equipment are
necessary for optimal management. Any patient with the aforementioned pre-existing
conditions and who is to be transferred should be intubated and ventilated.
B. Myocardial Contusion
Myocardial contusion, although difficult to diagnose, is another potentially lethal injury
from blunt chest trauma. The patient's reported complaints of discomfort are often bypassed
as being associated with chest wall contusion or fractures of the sternum and/or ribs. The
diagnosis of myocardial contusion is established by abnormalities on the electrocardiogram,
two-dimensional echocardiography, and associated history of injury. The electrocardiographic
changes are variable and may even indicate frank myocardial infarction. Multiple premature
ventricular contractions, unexplained sinus tachycardia, atrial fibrillation, bundle branch block
(usually right), and ST segment changes are the most common electrocardiographic findings.
8

Elevated central venous pressure in the absence of obvious cause may indicate right
ventricular dysfunction secondary to contusion.
Patients with myocardial contusion are at risk for sudden dysrhythmias. They should
be admitted to the critical care unit for close observation and cardiac monitoring.
C. Traumatic Aortic Rupture
Traumatic aortic rupture is a common cause of sudden death after an automobile
collision or a fall from a great height. Tears of the aorta and major pulmonary arteries, most
of which result from blunt trauma, are usually fatal at the scene. For survivors, salvage is
frequently possible, if aortic rupture is identified and treated early.
Patients with aortic rupture, who are potentially salvageable, tend to have a laceration
near the ligamentum arteriosum of the aorta. Continuity maintained by an intact adventitial
layer prevents immediate death. Many of the surviving patients die in the hospital if left
untreated. Some blood may escape into the mediastinum, but one characteristic shared by all
survivors is that this is a contained hematoma. Other than the initial pressure drop associated
with the loss of 500 mL to 1000 mL of blood, hypotension responds to intravascular infusion.
Persistent or recurrent hypotension is usually due to an unidentified bleeding site. Although
free rupture of a transected aorta into the left chest does occur and causes hypotension, it is
usually fatal unless the patient is operated on within a few minutes.
Specific signs and symptoms are frequently absent. A high index of suspicion triggered
by a history of decelerating force and characteristic radiologic findings, followed by
arteriography, are the means of making the diagnosis. Angiography should be performed
liberally because the findings of the chest roentgenogram, especially the supine view, are
unreliable. Approximately 10% of the aortograms will be positive for aortic rupture if liberal
indications for using angiography are employed for all patients with widened mediastinum.
Adjunctive radiologic signs, which may or may not be present, indicate the likelihood of
major vascular injury in the chest. They include:
1. Widened mediastinum.
2. Fractures of the first and second ribs.
3. Obliteration of the aortic knob.
4. Deviation of the trachea to the right.
5. Presence of a pleural cap.
6. Elevation and rightward shift of the right mainstem bronchus.
7. Depression of the left mainstem bronchus.
8. Obliteration of space between the pulmonary artery and the aorta.

9. Deviation of the esophagus (nasogastric tube) to the right.

False-positive and false-negative findings occur with each roentgenographic sign.
Therefore, no single finding reliably predicts or excludes significant injury. A widened
mediastinum is the most consistent finding. The slightest suspicion of aortic injury should be
evaluated angiographically, which is considered the gold standard. Transesophageal
ultrasonography may be a useful diagnostic tool. Computed tomography (CT) is time
consuming and may not provide a definitive diagnosis.
The treatment is either direct repair of the aorta or resection of the injured area and
grafting. A qualified surgeon should treat such a patient.
D. Traumatic Diaphragmatic Rupture
A traumatic diaphragmatic rupture is more commonly diagnosed on the left side
because the liver obliterates the defect on the right side, while the appearance of bowel,
stomach, or nasogastric tube is more easily detected in the left chest. Blunt trauma produces
large radial tears that lead to herniation. Penetrating trauma produces small perforations that
often take some time, even years, to develop into diaphragmatic hernias.
These injuries are missed initially if the chest film is misinterpreted as showing an
elevated left diaphragm, acute gastric dilatation, a loculated pneumohemothorax, or
subpulmonary hematoma. If a laceration of the left diaphragm is suspected, a gastric tube
should be inserted. When the gastric tube appears in the thoracic cavity on the chest film, the
need for special contrast studies is eliminated. Occasionally, the diagnosis is not identified on
the initial roentgenogram or after chest tube evacuation of the left thorax. An upper
gastrointestinal contrast study should be performed if the diagnosis is not clear. The
appearance of peritoneal lavage fluid in the chest tube drainage also confirms the diagnosis.
Right diaphragmatic ruptures are rarely diagnosed in the early postinjury period. The
liver often prevents herniation of other abdominal organs into the chest. The appearance of
an elevated right diaphragm on chest roentgenogram may be the only finding. Operation for
other abdominal injuries often reveals diaphragmatic tears. The treatment is direct repair.
E. Tracheobronchial Tree Injuries
1. larynx
Fracture of the larynx is a rare injury, and is indicated by the following triad:
a. Hoarseness
b. Subcutaneous emphysema
c. Palpable fracture crepitus.
If the patient's airway is totally obstructed or the patient is in severe respiratory
distress, an attempt at intubation is warranted. If intubation is unsuccessful, a tracheostomy
10

(not surgical cricothyroidotomy) is indicated, followed by operative repair. If the patient has
sustained blunt trauma to the larynx, exhibits subtle symptoms, and a fracture is suspected,
computed tomography may be helpful in identifying a fracture of the larynx.
2. Trachea
Direct trauma to the trachea, including the larynx, can be either penetrating or blunt.
Blunt injuries may be subtle, and history is all-important.
Penetrating trauma is overt and requires immediate surgical repair. Penetrating injuries
are often associated with esophageal, carotid artery, and jugular vein trauma. Because of the
blast effect, penetrating injuries caused by missiles are often associated with extensive tissue
destruction surrounding the area of penetration.
Noisy breathing indicates partial airway obstruction that suddenly may become
complete. Absence of breathing suggests that complete obstruction already exists. When the
level of consciousness is depressed, detection of significant airway obstruction is more subtle.
Observations of labored respiratory effort may be the only clue to airway obstruction and
tracheobronchial injury. Endoscopic procedures and CT scanning aid the diagnosis.
3. Bronchus
Injury to a major bronchus is an unusual and fatal injury that is frequently overlooked.
The majority of such injuries result from blunt trauma and occur within one inch of the
carina. Although most patients with this injury die at the scene, those who reach the hospital
alive have a 30% mortality, often due to associated injuries.
If suspicion of a bronchial injury exists, immediate surgical consultation is warranted.
A patient with a bronchial injury frequently presents with hemoptysis, subcutaneous
emphysema, or tension pneumothorax with a mediastinal shift. A pneumothorax associated
with a persistent large air leak after tube thoracotomy suggests a bronchial injury. More than
one chest tube may be necessary to overcome a very large leak. Bronchoscopy confirms the
diagnosis of the injury.
Treatment of tracheobronchial injuries may require only airway maintenance until the
acute inflammatory and edema processes resolve. Major deviation or compression of the
trachea by extrinsic masses, ie, hematomas, must be treated. Intubation frequently may be
unsuccessful because of the anatomic distortion from paratracheal hematoma, major
laryngotracheal injury, and associated injuries. For such patients, operative intervention is
indicated. Patients surviving with bronchial injuries may require direct surgical intervention
by thoracotomy.
F. Esophageal Trauma
Esophageal trauma is most commonly penetrating. Blunt esophageal trauma, although
very rare, may be lethal if unrecognized. Blunt injury of the esophagus is caused by a forceful
expulsion of gastric contents into the esophagus from a severe blow to the upper abdomen.
This forceful ejection produces a linear tear in the lower esophagus, allowing leakage into the
11

mediastinum. The resulting mediastinitis and immediate or delayed rupture into the pleural
space cause empyema. Esophageal trauma may be caused by mishaps of instrumentation
(nasogastric tubes, endoscopes, dilators, etc).
The clinical picture is identical to that of postemetic esophageal rupture. Esophageal
injury should be considered for any patient who (1) has a left pneumothorax or hemothorax
without a rib fracture, (2) has received a severe blow to the lower sternum or epigastrium and
is in pain or shock out of proportion to the apparent injury, or (3) has particulate matter in
their chest tube after the blood begins to clear. Presence of mediastinal air also suggests the
diagnosis, which often can be confirmed by contrast studies and/or esophagoscopy.
Wide drainage of the pleural space and mediastinum with direct repair of the injury
via thoracotomy is the treatment if feasible. If the repair is tenuous or not feasible, esophageal
diversion in the neck and gastrostomy of the lower and upper gastric segments usually is
carried out, thereby avoiding continued soiling of the mediastinum and pleura by gastric and
esophageal contents.
V. Other Manifestations of Chest Injuries
A. Subcutaneous Emphysema
Subcutaneous emphysema may result from airway injury, lung injury, or rarely, blast
injury. Although it does not require treatment, the underlying injury must be addressed.
B. Crushing Injury to the Chest (Traumatic Asphyxia)
Findings associated with a crush injury to the chest include upper torso, facial, and
arm plethora with petechiae secondary to superior vena cava compression. Massive swelling
and even cerebral edema may be present. Underlying injuries must be treated.
C. Simple Pneumothorax
Pneumothorax results from air entering the potential space between the visceral and
parietal pleura. Both penetrating and nonpenetrating trauma may cause this injury. Lung
laceration with air leakage is the most common cause of pneumothorax resulting from blunt
trauma.
The thorax is normally completely filled by the lung, held to the chest wall by surface
tension between the pleural surfaces. Air in the pleural space collapses lung tissue. This
collapsed lung does not participate in oxygen exchange. A ventilation/perfusion defect occurs
because the blood circulated to the nonventilated area is not oxygenated.
When a pneumothorax is present, breath sounds are decreased on the affected side.
Percussion demonstrates hyperresonance. An upright, expiratory roentgenogram of the chest
aids the diagnosis.
A pneumothorax is best treated with a chest tube in the fourth or fifth intercostal
space, anterior to the midaxillary line. Observation and/or aspiration of any pneumothorax is
12

risky. Once a chest tube has been inserted and connected to an underwater seal apparatus with
or without suction, a chest roentgenogram is necessary to confirm re-expansion of the lung.
General anesthesia should never be administered for definitive care of injuries in patients who
have sustained traumatic pneumothorax or who are at risk for unexpected intraoperative
pneumothorax, until a chest tube has been inserted. The chest also should be decompressed
before transporting the patient with a pneumothorax via air ambulance.
D. Hemothorax
The primary cause of hemothorax is lung laceration or laceration of an intercostal
vessel or internal mammary artery due to either penetrating or blunt trauma. In the vast
majority of cases this bleeding is self-limiting and does not require operative intervention.
Hemothorax, sufficient to appear on chest roentgenogram, is usually treated with a
large-caliber chest tube. The chest tube evacuates blood, reduces the risk of a clotted
hemothorax, and provides a method for monitoring blood loss. Although many factors are
involved in the decision to operate on a patient with a hemothorax, the amount of blood
drainage from the chest tube is a major factor. If a liter of blood is obtained through the chest
tube, surgical consultation is warranted. Persistent drainage of more than 200 mL per hour
for four hours may indicate the need for thoracotomy.
E. Scapular and Rib Fractures
The ribs are the most commonly injured component of the thoracic cage. Injuries to
the ribs are often significant. Pain on motion results in splinting of the thorax, which impairs
ventilation. Tracheobronchial secretions cannot be eliminated easily. The incidence of
atelectasis and pneumonia rises strongly with pre-existing lung disease.
The upper ribs (1 to 3) are protected by the bony framework of the upper limb. The
scapula, humerus, and clavicle, along with their muscular attachments, provide a barrier to
rib and scapular injury. Fractures of the scapula, and first or second ribs often indicate major
injury to the head, neck, spinal cord, lungs, and the great vessels. Because of the severity of
the associated injuries, mortality can be as high as 50%. Surgical consultation is warranted.
The middle ribs (4 to 9) sustain the majority of blunt trauma. Anteroposterior
compression of the thoracic cage will bow the ribs outward with a fracture in the midshaft.
Direct force applied to the ribs tends to fracture them and drive the ends of the bones into the
thorax with more potential for intrathoracic injury, such as pneumothorax. As a general rule,
a young patient with a more flexible chest wall is less likely to sustain rib fractures.
Therefore, the presence of multiple rib fractures in young patients implies a greater transfer
of force than in older patients. Fractures of the lower ribs (10 to 12) should increase suspicion
for hepatosplenic injury.
Localized pain, tenderness on palpation, and crepitus are present in rib injury patients.
A palpable or visible deformity suggests rib fractures. A chest roentgenogram should be
obtained primarily to exclude other intrathoracic injuries and not just to identify rib fractures.
Fractures of anterior cartilages or separation of costochondral junctions have the same
implications as rib fractures, but will not be seen on the roentgenographic examinations.
13

Special rib technique roentgenograms are expensive, may not detect all rib injuries, add
nothing to treatment, require painful positioning of the patient, and are not useful. Taping, rib
belts, and external splints are contraindicated. Relief of pain is important to enable adequate
ventilation. Intercostal block, epidural anesthesia, and systemic analgesics may be necessary.
F. Other Indications for Chest Tube Insertion
1. Selected patients with suspected severe lung injury, especially those being
transferred by air or ground vehicle.
2. Individuals undergoing general anesthesia for treatment of other injuries (eg, cranial
or extremity), who have suspected significant lung injury.
3. Individuals requiring positive pressure ventilation who are suspected of having
substantial chest injury.
VI. Summary
Thoracic trauma is common in the multiple-injured patient and can be associated with
life-threatening problems. These patients can usually be treated or their conditions temporarily
relieved by relatively simple measures such as intubation, ventilation, tube thoracostomy, and
needle pericardiocentesis. The ability to recognize these important injuries and the skill to
perform the necessary procedures can be life-saving.

14

Skill Station VI: Roentgenographic Identification of Thoracic Injuries

Resources and Equipment
This list is the recommended equipment to conduct this skill session in accordance
with the stated objectives for and intent of the procedures outlined. Additional equipment may
be used providing it does not detract from the stated objectives and intent of this skill or from
performing the procedure in a safe manner as described and recommended by the ACS
Committee on Trauma.
1. Thoracic roentgenograms (available from the ACS, ATLS Division)
2. Identification key to roentgenograms
3. View boxes to display films.
Objectives
1. Upon completion of this station, the participant will be able to identify various
thoracic injuries by using six specific anatomic guidelines for examining a series of chest
roentgenograms.
a. Soft tissues of the chest wall
b. Bony thorax
c. Pleural spaces and lung parenchyma
d. Trachea and bronchi
e. Diaphragm
f. Mediastinum
2. Given a series of roentgenograms, the participant will be able to:
a. Diagnose fractures.
b. Delineate associated injuries.
c. Define other areas of possible injury.
Skill Procedure: Roentgenographic Identification of Thoracic Injuries
Note: Chest roentgenograms are obtained during the primary survey/resuscitation
phase or the secondary survey, based on the urgency of the patient's condition. Six-foot,
upright films provide better anatomic detail of the chest; however, practicality and safety
dictate that anteroposterior (AP), supine films are adequate for identifying injuries in the
15

potentially or obviously unstable patient. For example, when the patient's torso or neck has
been injured or when the unconscious patient is at risk of aspirating, an AP supine
roentgenogram should be obtained. A lateral thoracic film may be necessary to identify a
suspected sternal fracture.
A systematic review of the roentgenogram must be performed, preferably using a view
box. The anatomic guidelines outlined herein identify areas in the thorax that should be
assessed when examining a chest film. Each of these areas should be assessed for potential
injury when viewing the specific roentgenograms associated with this skill station. (See
Resource Document 5, Roentgenographic Studies.)
I. Soft Tissues
Asses for:
1. Displacement or disruption of tissue planes
2. Evidence of subcutaneous air.
II. Bony Thorax
A. Clavicle
Assess for evidence of:
1. Fracture
2. Associated injury, eg, great vessel injury.
B. Scapula
Assess for evidence of:
1. Fracture
2. Associated injury, eg, airway or great vessel injury, pulmonary contusion.
C. Ribs
1. Ribs 1 through 3: Assess for evidence of:
a. Fracture
b. Associated injury, eg, pneumothorax, major airway or great vessel injury.
2. Ribs 4 through 9: Assess evidence of:
a. Fracture, especially in two or more contiguous ribs in two places (flail chest).
16

b. Associated injury, eg, pneumothorax, hemothorax, pulmonary contusion.

3. Ribs 9 through 12: Assess for evidence of:
a. Fracture, especially in two or more places (flail chest).
b. Associated injury, eg, pneumothorax, pulmonary contusion, spleen, liver, and/or
kidney.
D. Sternum
1. Assess the sternoclavicular junction and sternal body for evidence of fracture.
(Sternal fractures may be confused on the AP film as a mediastinal hematoma. After the
patient is stabilized, a coned-down view, over-penetrated film, lateral view, or CT may be
obtained to better illuminate a suspected sternal fracture.)
2. Assess for associated injuries, eg, myocardial contusion, great vessel injury
(widened mediastinum).
III. Pleural Space and Lung Parenchyma
A. Pleural Space
1. Assess for abnormal collections of fluid that may represent a pneumothorax.
2. Assess for abnormal collections of air that may represent a pneumothorax - usually
seen as an apical lucent area absent of bronchial or vascular markings.
B. Lung Parenchyma
1. Assess the lung fields for infiltrates that may suggest pulmonary contusion,
hematoma, aspiration, etc. Pulmonary contusion appears as air space consolidation that can
be irregular and patchy or homogenous, diffuse, or extensive.
2. Assess the parenchyma for evidence of laceration. Lacerations appear as a
hematoma, vary according to the magnitude of injury, and appear as areas of consolidation.
IV. Trachea and Bronchi
A. Assess for the presence of interstitial or pleural air that may represent a large
airway injury.
B. Assess for tracheal lacerations that may present as pneumomediastinum,
pneumothorax, subcutaneous and interstitial emphysema of the neck, or pneumoperitoneum.
C. Assess for bronchial disruption that may present as a free pleural communication
producing a massive pneumothorax with a persistent air leak that is unresponsive to tube
thoracostomy.
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V. Diaphragm
Diaphragmatic rupture requires a high index of suspicion, based on the mechanism of
injury, the patient's signs and symptoms, and roentgenographic findings. Initial chest
roentgenograms may not clearly identify a diaphragmatic injury. Sequential films or additional
studies may be required.
A. Carefully evaluate the diaphragm for:
1. Elevation (may rise to fourth intercostal space with full expiration)
2. Disruption (stomach or bowel gas above the diaphragm)
3. Poor identification (irregular or obscure) due to overlying fluid or soft tissue
masses.
B. Roentgenographic changes suggesting injury include:
1. Elevation, irregularity, or obliteration of the diaphragm - segmental or total
2. Mass-like density above the diaphragm may be due to a fluid-filled bowel,
omentum, liver, kidney, spleen, or pancreas (may appear as a "loculated pneumothorax")
3. Air or contrast-containing stomach or bowel above the diaphragm
4. Contralateral mediastinal shift
5. Widening of the cardiac silhouette if the peritoneal contents herniate into the
pericardial sac
6. Pleural effusion
7. The inferior border of the liver may appear higher than expected; lower rib
fractures, pulmonary contusions, and the appearance of foreign bodies in the chest cavity may
be associated with diaphragmatic injury; eg, a nasogastric tube coiled in the chest may
represent a stomach herniated into the thorax or a hole in the esophagus.
C. Assess for associated injuries, eg, splenic, pancreatic, renal, and liver.
VI. Mediastinum
A. Assess for air or blood that may either displace mediastinal structures, blur the
demarcation between tissue planes, or outline them with radiolucency.
B. Assess for radiologic signs associated with cardiac or major vascular injury.
1. Air or blood in the pericardium may result in an enlarged cardiac silhouette.
Progressive changes in the cardiac size may represent an expanding pneumopericardium or
18

hemopericardium.
2. Aortic rupture may be suggested by:
a. Widened mediastinum - most reliable finding
b. Fractures of the first and second ribs
c. Obliteration of the aortic know
d. Deviation of the trachea to the right
e. Presence of a pleural cap
f. Elevation and rightward shift of the right mainstem bronchus
g. Depression of the left mainstem bronchus
h. Obliteration of the space between the pulmonary artery and the aorta
i. Deviation of the esophagus (nasogastric tube) to the right.
VII. Roentgenographic Assessment
After careful, systematic evaluation of the initial chest film, additional roentgenograms
or radiographic studies may be necessary as historical facts or physical findings dictate. For
example, repeat chest films may be indicated if significant changes in the patient's status
develop. Computed tomography and arteriography may be indicated for specificity of
diagnosis.

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Table 1. Chest Roentgenographic Suggestions

Abnormal Findings

Diagnoses to Consider

Any rib fracture

Fracture, first 3 ribs
Lower ribs, 9 to 12
Two or more rib fractures
in two or more places
GI gas pattern in the chest
(loculated air)
NG tube in the chest

Pneumothorax
Airway or great vessel injury
Abdominal injury
Flail chest, pulmonary contusion

Air fluid level in the chest

Sternal fracture
Mediastinal hematoma
Disrupted diaphragm
Respiratory distress without
roentgenographic findings
Persistent large pneumothorax
after chest tube insertion
Mediastinal air
Scapular fracture
Free air under the diaphragm

Diaphragmatic rupture
Diaphragmatic rupture or ruptured
esophagus
Hemothorax or diaphragmatic rupture
Myocardial contusion, head injury, cspine injury
Great vessel injury, sternal fracture
Abdominal visceral injury
CNS injury, aspiration
Bronchial tear, esophageal
disruption
Esophageal disruption,
pneumoperitoneum, tracheal injury
Airway or great vessel injury, or
pulmonary contusion
Ruptured hollow abdominal viscus.

20

Skill Station VII: Chest Trauma Management

These surgical procedures, if performed on a live, anesthetized animal, must be
conducted in a USDA-Registered Animal Laboratory Facility. (See ATLS Instructor
Manual, Section II, Chapter 9 - Policies, Procedures, and Protocols for Surgical Skills
Practicum.)
Resources and Equipment
This list is the recommended equipment to conduct this skill session in accordance
with the stated objectives for and intent of the procedures outlined. Additional equipment may
be used providing it does not detract from the stated objectives and intent of this skill, or
from performing the procedure in a safe method as described and recommended by the ACS
Committee on Trauma.
1. Live, anesthetized animals
2. Licensed veterinarian (see guidelines referenced above)
3. Animal troughs, ropes (sandbags optional)
4. Animal intubation equipment
a. Endotracheal tubes
b. Laryngoscope blade and handle
c. Respirator with 15-mm adapter
5. Electric shears with #40 blade
6. Tables or instrument stand
7. Needles and catheters
a. Assorted #14-gauge over-the-needle catheters (3 to 6 cm in length)
b. #18-gauge spinal needles (5 to 6 inches or 12.7 to 15.2 cm in length)
c. #22-gauge spinal needles (5 to 6 inches or 12.7 to 15.2 cm in length)
d. Pericardiocentesis catheter kit (optional)
8. Syringes
a. 6-mL syringes
b. 12-mL syringes
c. 35-mL syringes, plastic and glass
9. Suture
a. 2-0 and 3-0 silk with cutting needle
b. 2-0 and 3-0 silk with taper needle
21

c. 4-0 Monofilament/noncutting needle (optional)

10. drugs
a. Lidocaine 1% (optional)
b. Heparin 1:1000 (optional)
11. Chest tubes without trocars - #32-French (for animal use); #36-40 French (for
patient use)
12. 3x3 or 4x4 gauze sponges
13. One-inch (2.5 cm) adhesive tape
14. Underwater seal device
15. Small basin for water to inject into the pericardial sac (methylene-blue dye may
be added to the water for a more dramatic appearance when performing pericardiocentesis)
16. Flutter-type valve
17. Three-way stopcocks
18. Surgical instruments
a. Scalpel handles with #10 and #11 blades
b. Needle holders
c. Small Finochetti chest retractors or small self-retaining chest retractors
d. Mosquitoes
e. Heavy curved scissors
f. Suture scissors
g. Metsenbaum curved dissecting scissors
h. Tissue forceps - with and without teeth
19. Antiseptic swabs
20. Surgical drapes (optional)
21. Electrocardiographic monitor (optional)
22. Surgical garb (gloves, shoe covers, and scrub suits or cover gowns).
Objectives
1. Performance at this station will allow the participant to practice and demonstrate
on a live, anesthetized animal the technique of inserting a chest needle and chest tube for the
emergency care of hemothoraces and/or pneumothoraces.

22

2. Upon completion of this station, the participant will be able to describe the surface
markings and technique for pleural decompression with needle thoracocentesis and chest tube
insertion.
3. Upon completion of this station, the participant will be able to discuss the
underlying pathophysiology of cardiac tamponade as a result of trauma.
4. Upon completion of this station, the participant will be able to describe the surface
markings and technique for pericardiocentesis.
5. Performance at this station will allow the participant to practice and demonstrate
on a live, anesthetized animal the technique of inserting a needle into the pericardium
(pericardiocentesis) for the emergency treatment of cardiac tamponade or hemopericardium.
6. Upon completion of this station, the participant will be able to discuss the
complications of needle thoracocentesis, chest tube insertion, and pericardiocentesis.
Procedures
1. Needle thoracocentesis
2. Chest tube insertion
3. Pericardiocentesis.

23

Skills Procedures: Chest Trauma Management

Note: Universal precautions are required whenever caring for the trauma patient.
I. Needle Thoracocentesis
Note: This procedure is for the rapidly deteriorating critical patient who has a
life-threatening tension pneumothorax. If this technique is used and the patient does not
have a tension pneumothorax, a pneumothorax and/or damage to the lung may occur.
A. Assess the patient's chest and respiratory status.
B. Administer high-flow oxygen and ventilate as necessary.
C. Identify the second intercostal space, in the midclavicular line on the side of the
tension pneumothorax.
D. Surgically prepare the chest.
E. Locally anesthetize the area if the patient is conscious or if time permits.
F. Place the patient in an upright position if a cervical spine injury has been excluded.
G. Keeping the Luer-Lok in the distal end of the catheter, insert an over-the-needle
catheter (3 to 6 cm long) into the skin and direct the needle just over (ie, superior to) the rib
into the intercostal space.
H. Puncture the parietal pleura.
I. remove the Luer-Lok from the catheter and listen for a sudden escape of air when
the needle enters the parietal pleura, indicating that the tension pneumothorax has been
relieved.
J. Remove the needle and replace the Luer-Lok in the distal end of the catheter. Leave
the plastic catheter in place and apply a bandage or small dressing over the insertion site.
K. Prepare for a chest-tube insertion, if necessary. The chest tube should be inserted
at the nipple level anterior to the midaxillary line of the affected hemithorax.
L. Connect the chest tube to an underwater seal device or a flutter-type-valve
apparatus and remove the catheter used to relieve the tension pneumothorax initially.
M. Obtain a chest roentgenogram.

24

Complications of Needle Thoracocentesis

1.
2.
3.
4.

Local cellulitis
Local hematoma
Pleural infection, empyema
Pneumothorax

25

II. Chest Tube Insertion

A. Fluid resuscitation via at least one, large-caliber intravenous catheter, and
monitoring of vital signs should be in process.
B. Determine the insertion site - usually the nipple level (5th intercostal space) anterior
to the midaxillary line on the affected side. A second chest tube may be used for a
hemothorax.
C. Surgically prepare and drape the chest at the predetermined site of the tube
insertion.
D. Locally anesthetize the skin and rib periosteum.
E. Make a 2- to 3-cm transverse (horizontal) incision at the predetermined site and
bluntly dissect through the subcutaneous tissues, just over the top of the rib.
F. Puncture the parietal pleura with the tip of a clamp and put a gloved finger into the
incision to avoid injury to other organs and to clear any adhesions, clots, etc.
G. Clamp the proximal end of the thoracostomy tube and advance the thoracostomy
tube into the pleural space to the desired length.
H. Look for "fogging" of the chest tube with expiration or listen for air movement.
I. Connect the end of the thoracostomy tube to an underwater-seal apparatus.
J. Suture the tube in place.
K. Apply a dressing, and tape the tube to the chest.
L. Obtain a chest roentgenogram.
M. Obtain arterial blood gas values as necessary.
Complications of Chest Tube Insertion
1. Anaphylactic or allergic reaction to surgical preparation or anesthetic.
2. Chest tube dislodgment from the chest wall or disconnection from the underwaterseal apparatus.
3. Chest bottle elevated above the level of the chest, and fluid flows into the chest
cavity.
4. Chest tube kinking or clogging.
5. Damage to the intercostal nerve, artery, or vein
26

a. Converting a pneumothorax to a hemopneumothorax

b. Resulting in intercostal neuritis/neuralgia
6. Damage to internal mammary vessels if puncture is too medial, resulting in
hemopneumothorax
7. Incorrect tube position, extrathoracic or intrathoracic
8. Intercostal myalgia
9. Introduction of pleural infection (eg, thoracic empyema)
10. Laceration or puncture of intrathoracic and/or abdominal organs, all of which can
be prevented by using the finger technique before inserting the chest tube
a. Heart
b. Lung
c. Esophagus
d. Aorta
e. Pulmonary artery
f. Pulmonary vein
g. Long thoracic nerve
h. Mediastinum
i. Liver
j. Spleen
11. Leaky underwater-seal apparatus
12. Local cellulitis
13. Local hematoma
14. Mediastinal emphysema
15. Persistent pneumothorax
a. Large primary leak
b. Leak at the skin around the chest tube; suction on tube too strong
c. Leaky underwater-seal apparatus
16. Subcutaneous emphysema (usually at tube site)
17. Recurrence of pneumothorax upon removal of chest tube; seal of thoracostomy
wound not immediate
18. Lung fails to expand due to plugged bronchus; bronchoscopy required.
III. Pericardiocentesis
27

A. Monitor the patient's vital signs, CVP, and ECG before, during, and after the
procedure.
B. Surgically prepare the xiphoid and subxiphoid areas, if time allows.
C. Locally anesthetize the puncture site, if necessary.
D. Using a #16- to #18-gauge, 6-inch (15 cm) or longer over-the-needle catheter,
attach a 35-mL empty syringe with a three-way stopcock.
E. Assess the patient for any mediastinal shift that may have caused the heart to shift
significantly.
F. Puncture the skin 1 to 2 cm inferior to the left of the xiphochondral junction, at a
45-degree angle to the skin.
G. Carefully advance the needle cephalad and aim toward the tip of the left scapula.
H. If the needle is advanced too far (into the ventricular muscle) an injury pattern (eg,
extreme ST-T wave changes or widened and enlarged QRS complex) appears on the ECG
monitor. This pattern indicates that the pericardiocentesis needle should be withdrawn until
the previous baseline ECG tracing reappears. Premature ventricular contractions also may
occur, secondary to irritation of the ventricular myocardium.
I. When the needle tip enters the blood-filled pericardial sac, withdraw as much
nonclotted blood as possible.
J. During the aspiration, the epicardium reapproaches the inner pericardial surface, as
does the needle tip. Subsequently, an ECG injury pattern may reappear. This indicates that
the pericardiocentesis needle should be withdrawn slightly. Should this injury pattern, persist,
withdraw the needle completely.
K. After aspiration is completed, remove the syringe, and attach a three-way stopcock,
leaving the stopcock closed. Secure the catheter in place.
L. Should the cardiac tamponade symptoms persist, the stopcock may be opened and
the pericardial sac reaspirated. The plastic pericardiocentesis needle can be sutured or taped
in place and covered with a small dressing to allow for continued decompression en route to
surgery or transfer to another care facility.

28

Complication of Pericardiocentesis
1. Aspiration of ventricle blood instead of pericardial blood.
2. Cellulitis.
3. Laceration of coronary artery or vein.
4. Laceration of ventricular epicardium/myocardium.
5. New hemopericardium, secondary to lacerations of the coronary artery or vein,
and/or ventricular epicardium/myocardium.
6. Local hematoma.
7. Pericarditis.
8. Ventricular fibrillation.
9. Pneumothorax, secondary to lung puncture.
10. Puncture of aorta.
11. Puncture of inferior vena cava.
12. Puncture of esophagus.
13. Mediastinitis secondary to puncture of esophagus.
14. Puncture of peritoneum.
15. Peritonitis, secondary to puncture of peritoneum.

29