Thoracic trauma causes about 25% of traumatic deaths in the US. Many chest injuries cause death during the first minutes or hours after trauma; they can frequently be treated at the bedside with definitive or temporizing measures that do not require advanced surgical training.
Etiology of Thoracic Trauma
Chest injuries can result from blunt or penetrating trauma. The most important chest injuries include the following:
Pneumothorax (traumatic pneumothorax Pneumothorax Pneumothorax is air in the pleural space causing partial or complete lung collapse. Pneumothorax can occur spontaneously or result from trauma or medical procedures. Diagnosis is based on clinical... read more
, open pneumothorax Pneumothorax (Open) Open pneumothorax is a pneumothorax involving an unsealed opening in the chest wall; when the opening is sufficiently large, respiratory mechanics are impaired. (See also Overview of Thoracic... read more , and tension pneumothorax Pneumothorax (Tension) Tension pneumothorax is accumulation of air in the pleural space under pressure, compressing the lungs and decreasing venous return to the heart. (See also Overview of Thoracic Trauma.) Tension... read more )
Many patients have simultaneous hemothorax and pneumothorax (hemopneumothorax).
Bone injuries are common, typically involving the ribs Rib Fracture One or more ribs can be fractured due to blunt chest injury. (See also Overview of Thoracic Trauma.) This x-ray of the chest shows multiple fractures to the right ribs (seen on left). Typically... read more 
and clavicle Clavicle Fractures Clavicle fractures are among the most common fractures, particularly among children. Diagnosis is by plain x-ray. Most types are treated with a sling. (See also Overview of Fractures.) Clavicle... read more 
, but fractures of the sternum and scapula may occur. The esophagus and diaphragm (see Overview of Abdominal Trauma Overview of Abdominal Trauma The abdomen can be injured in many types of trauma; injury may be confined to the abdomen or be accompanied by severe, multisystem trauma. The nature and severity of abdominal injuries vary... read more ) also can be damaged by chest trauma. Because the diaphragm can be as high as the nipple line during exhalation, penetrating trauma to the chest at or below nipple level can also cause intra-abdominal injuries.
Pathophysiology of Thoracic Trauma
Most morbidity and mortality due to chest trauma occurs because injuries interfere with respiration, circulation, or both.
Respiration can be compromised by
Direct damage to the lungs or airways
Altered mechanics of breathing
Injuries that directly damage the lung or airways include pulmonary contusion and tracheobronchial disruption. Injuries that alter the mechanics of breathing include hemothorax Hemothorax Hemothorax is accumulation of blood in the pleural space. (See also Overview of Thoracic Trauma.) The usual cause of hemothorax is laceration of the lung, intercostal vessel, or an internal... read more 
, pneumothorax Pneumothorax (Traumatic) Traumatic pneumothorax is air in the pleural space resulting from trauma and causing partial or complete lung collapse. Symptoms include chest pain from the causative injury and sometimes dyspnea... read more , and flail chest Flail Chest Flail chest is multiple fractures in ≥ 3 adjacent ribs that result in a segment of the chest wall separating from the rest of the thoracic cage; it is a marker for injury to the underlying lung... read more . Injury to the lung, tracheobronchial tree, or rarely esophagus may allow air to enter the soft tissues of the chest and/or neck (subcutaneous emphysema) or mediastinum (pneumomediastinum Pneumomediastinum Pneumomediastinum is air in mediastinal interstices. The main causes of pneumomediastinum are Alveolar rupture with dissection of air into the interstitium of the lung with translocation to... read more 
). This air itself rarely has significant physiologic consequence; the underlying injury is the problem. Tension pneumothorax Pneumothorax (Tension) Tension pneumothorax is accumulation of air in the pleural space under pressure, compressing the lungs and decreasing venous return to the heart. (See also Overview of Thoracic Trauma.) Tension... read more impairs respiration as well as circulation.
Circulation can be impaired by
Bleeding
Decreased venous return
Direct cardiac injury
Bleeding, as occurs in hemothorax, can be massive, causing shock Shock Shock is a state of organ hypoperfusion with resultant cellular dysfunction and death. Mechanisms may involve decreased circulating volume, decreased cardiac output, and vasodilation, sometimes... read more (respiration is also impaired if hemothorax is large). Decreased venous return impairs cardiac filling, causing hypotension. Decreased venous return can occur due to increased intrathoracic pressure in tension pneumothorax or to increased intrapericardial pressure in cardiac tamponade Cardiac Tamponade Cardiac tamponade is accumulation of blood in the pericardial sac of sufficient volume and pressure to impair cardiac filling. Patients typically have hypotension, muffled heart tones, and distended... read more . Heart failure Heart Failure (HF) Heart failure (HF) is a syndrome of ventricular dysfunction. Left ventricular (LV) failure causes shortness of breath and fatigue, and right ventricular (RV) failure causes peripheral and abdominal... read more 
and/or conduction abnormalities can result from blunt cardiac injury Blunt Cardiac Injury Blunt cardiac injury is blunt chest trauma that causes contusion of myocardial muscle, rupture of a cardiac chamber, or disruption of a heart valve. Sometimes a blow to the anterior chest wall... read more that damages the myocardium or the heart valves.
Complications
Because chest wall injuries typically make breathing very painful, patients often limit inspiration (splinting). A common complication of splinting is atelectasis Atelectasis Atelectasis is collapse of lung tissue with loss of volume. Patients may have dyspnea or respiratory failure if atelectasis is extensive. They may also develop pneumonia. Atelectasis is usually... read more 
, which can lead to hypoxemia, pneumonia, or both.
Patients treated with tube thoracostomy Thoracotomy Thoracotomy is surgical opening of the chest. It is done to evaluate and treat pulmonary problems when noninvasive procedures are nondiagnostic or unlikely to be definitive. The principal indications... read more , particularly if a hemothorax is incompletely drained, may develop purulent intrathoracic infection (empyema).
Symptoms and Signs of Thoracic Trauma
Symptoms include pain, which usually worsens with breathing if the chest wall is injured, and sometimes shortness of breath.
Common findings include chest tenderness, ecchymoses, and respiratory distress; hypotension or shock may be present.
Neck vein distention can occur in tension pneumothorax Pneumothorax (Tension) Tension pneumothorax is accumulation of air in the pleural space under pressure, compressing the lungs and decreasing venous return to the heart. (See also Overview of Thoracic Trauma.) Tension... read more or cardiac tamponade Cardiac Tamponade Cardiac tamponade is accumulation of blood in the pericardial sac of sufficient volume and pressure to impair cardiac filling. Patients typically have hypotension, muffled heart tones, and distended... read more if patients have sufficient intravascular volume.
Decreased breath sounds can result from pneumothorax or hemothorax Hemothorax Hemothorax is accumulation of blood in the pleural space. (See also Overview of Thoracic Trauma.) The usual cause of hemothorax is laceration of the lung, intercostal vessel, or an internal... read more ; percussion over the affected areas is dull with hemothorax and hyperresonant with pneumothorax.
The trachea can deviate away from the side of a tension pneumothorax.
In flail chest Flail Chest Flail chest is multiple fractures in ≥ 3 adjacent ribs that result in a segment of the chest wall separating from the rest of the thoracic cage; it is a marker for injury to the underlying lung... read more , a segment of the chest wall moves paradoxically—that is, in the opposite direction from the rest of the chest wall (outward during expiration and inward during inspiration); the flail segment is often palpable.
Subcutaneous emphysema causes a crackling or crunch when palpated. Findings may be localized to a small area or involve a large portion of the chest wall and/or extend to the neck. Most often, pneumothorax is the cause; when extensive, injury to the tracheobronchial tree or upper airway should be considered. Air in the mediastinum may produce a characteristic crunching sound synchronous with the heartbeat (Hamman sign or Hamman crunch). Hamman sign suggests pneumomediastinum Pneumomediastinum Pneumomediastinum is air in mediastinal interstices. The main causes of pneumomediastinum are Alveolar rupture with dissection of air into the interstitium of the lung with translocation to... read more and often tracheobronchial tree injury or, rarely, esophageal injury.
Diagnosis of Thoracic Trauma
Clinical evaluation
Chest x-ray
Sometimes other imaging studies (eg, CT, ultrasonography, aortic imaging studies)
Clinical evaluation
Five conditions are immediately life threatening and rapidly correctable:
Massive hemothorax
Diagnosis and treatment begin during the primary survey (see Approach to the Trauma Patient Approach to the Trauma Patient Injury is the number one cause of death for people aged 1 to 44. In the US, there were 278,345 trauma deaths in 2020, about 70% of which were accidental. Of intentional injury deaths, more than... read more ) and are based first on clinical findings. Depth and symmetry of chest wall excursion are assessed, the lungs are auscultated, and the entire chest wall and neck are inspected and palpated. Patients in respiratory distress should be monitored with serial assessments of clinical status and of oxygenation plus ventilation (eg, with pulse oximetry, arterial blood gas tests, capnometry if intubated).
Penetrating chest wounds should not be probed. However, their location helps predict risk of injury. High-risk wounds are those medial to the nipples or scapulae and those that traverse the chest from side to side (ie, entering one hemithorax and exiting the other). Such wounds may injure the hilar or great vessels, heart, tracheobronchial tree, or rarely the esophagus.
Patients with symptoms of partial or complete airway obstruction following blunt trauma should be immediately intubated to control the airway.
In patients with difficulty breathing, severe injuries to consider during the primary survey include the following:
Tension pneumothorax
Open pneumothorax
Massive hemothorax
Flail chest
There is a simplified, rapid approach to help differentiate these injuries (see figure A simplified, rapid approach to assessment of patients with chest trauma A simple, rapid assessment of patients with thoracic trauma and respiratory distress during the primary survey 
).
A simplified, rapid assessment of patients with thoracic trauma and respiratory distress during the primary survey
 |
In patients with thoracic trauma and impaired circulation (signs of shock Shock Shock is a state of organ hypoperfusion with resultant cellular dysfunction and death. Mechanisms may involve decreased circulating volume, decreased cardiac output, and vasodilation, sometimes... read more ), severe injuries to consider during the primary survey include the following:
Massive hemothorax
Tension pneumothorax
Cardiac tamponade
Other chest injuries (eg, blunt cardiac injury, aortic disruption) may cause shock but are not treated during the primary survey. Simplified, rapid approaches can help differentiate among rapidly correctable causes of shock due to chest injuries (see figure A simplified, rapid assessment for chest injuries in patients with shock... A simple, rapid assessment for chest injuries in patients with shock during the primary survey 
). However, hemorrhage should be excluded in all patients who have shock after major trauma, regardless of whether a chest injury that could cause shock is identified.
A simplified, rapid assessment for chest injuries in patients with shock during the primary survey
 * Hemorrhage should be excluded in all patients who are in shock after major trauma, regardless of whether a chest injury that could cause shock is identified † Neck vein distention may be absent in patients with hypovolemic shock. |
Treatment of injuries affecting the airway, breathing, or circulation begins during the primary survey. After the primary survey, patients are clinically assessed in more detail for other severe chest injuries as well as less severe manifestations of the injuries considered during the primary survey.
Imaging
Imaging studies are typically required in patients with significant chest trauma. Chest x-ray is virtually always done. Results are usually diagnostic of certain injuries (eg, pneumothorax, hemothorax, moderate or severe pulmonary contusion, clavicle fracture, some rib fractures) and suggestive for others (eg, aortic disruption, diaphragmatic rupture). However, findings may evolve over hours (eg, in pulmonary contusion Pulmonary Contusion Pulmonary contusion is trauma-induced lung hemorrhage and edema without laceration. (See also Overview of Thoracic Trauma.) Pulmonary contusion is a common and potentially lethal chest injury... read more and diaphragmatic injury). Plain x-rays of the scapula or sternum are sometimes done when there is tenderness over those structures.
In trauma centers, during the E-FAST (Extended Focused Assessment With Sonography in Trauma) examination How To Do E-FAST Examination E-FAST (Extended Focused Assessment with Sonography in Trauma) is a bedside ultrasonographic protocol designed to detect peritoneal fluid, pericardial fluid, pneumothorax, and/or hemothorax... read more 
, ultrasonography of the heart is typically done during the resuscitation phase to look for pericardial tamponade; some pneumothoraces can also be seen.
CT of the chest is often done when aortic injury Aortic Disruption (Traumatic) The aorta can rupture completely or incompletely after blunt or penetrating chest trauma. Signs may include asymmetric pulses or blood pressure, decreased blood flow to the lower extremities... read more is suspected and to diagnose small pneumothoraces, sternal and rib fractures, or mediastinal (eg, heart, esophageal, bronchial) injuries; thoracic spine injuries also will be identified.
Other tests for aortic injury include aortography Uses of Angiography Angiography is sometimes called conventional angiography to distinguish it from CT angiography (CTA) and magnetic resonance angiography (MRA). Angiography provides detailed images of blood vessels... read more 
and transesophageal echocardiography Techniques 
.
Laboratory and other testing
Complete blood count is often done but is mainly valuable as a baseline for detecting ongoing hemorrhage. Arterial blood gas results help monitor patients with hypoxia or respiratory distress. Cardiac markers (eg, troponin, creatine phosphokinase muscle band isoenzyme [CPK-MB]) can help exclude blunt cardiac injury.
ECG is typically done for chest trauma that is severe or compatible with cardiac injury. Cardiac injury may cause arrhythmia, conduction abnormalities, ST segment abnormalities, or a combination.
Treatment of Thoracic Trauma
Supportive care
Treatment of specific injuries
Immediately life-threatening injuries are treated at the bedside at the time of diagnosis:
Respiratory distress with suspected tension pneumothorax Pneumothorax (Tension) Tension pneumothorax is accumulation of air in the pleural space under pressure, compressing the lungs and decreasing venous return to the heart. (See also Overview of Thoracic Trauma.) Tension... read more
: Needle decompression Respiratory distress or shock with decreased breath sounds and suspected hemothorax: Tube thoracostomy How To Do Tube and Catheter Thoracostomy Surgical tube thoracostomy is insertion of a surgical tube into the pleural space to drain air or fluid from the chest. Pneumothorax that is recurrent, persistent, traumatic, large, under tension... read more
Respiratory distress with suspected open pneumothorax: Partially occlusive dressing followed by tube thoracostomy
Respiratory distress with suspected flail chest: Mechanical ventilation Overview of Mechanical Ventilation Mechanical ventilation can be Noninvasive, involving various types of face masks Invasive, involving endotracheal intubation Selection and use of appropriate techniques require an understanding... read more
Immediate resuscitative thoracotomy can be considered for trauma victims if the clinician is proficient in the procedure and the patient has one of the following indications:
Penetrating thoracic injury with a need for cardiopulmonary resuscitation (CPR) of < 15 minutes
Penetrating nonthoracic trauma with a need for CPR of < 5 minutes
Blunt trauma with a need for CPR of < 10 minutes
Persistent systolic blood pressure of < 60 mm Hg due to suspected cardiac tamponade, hemorrhage, or air embolism
In the absence of any of these criteria, resuscitative thoracotomy is contraindicated because the procedure has significant risks (eg, transmission of blood-borne diseases, injury to clinician) and costs.
Specific treatment is directed at the injury. Supportive therapy typically includes analgesics, supplemental oxygen, and sometimes mechanical ventilation Overview of Mechanical Ventilation Mechanical ventilation can be Noninvasive, involving various types of face masks Invasive, involving endotracheal intubation Selection and use of appropriate techniques require an understanding... read more .
