Chest trauma is a significant source of morbidity and mortality in the United States.

This article focuses on

chest trauma caused by blunt mechanisms. Penetrating thoracic injuries are addressed in Penetrating
Chest Trauma.
Blunt injury to the chest can affect any one or all components of the chest wall and thoracic cavity. These
components include the bony skeleton ribs! clavicles! scapulae! sternum"! lungs and pleurae!
tracheobronchial tree! esophagus! heart! great vessels of the chest! and the diaphragm. #n the
subse$uent sections! each particular injury and injury pattern resulting from blunt mechanisms is
discussed. The pathophysiology of these injuries is elucidated! and diagnostic and treatment measures
are outlined.
Historical perspective
%ecords describing chest trauma and its treatment date to anti$uity. &n ancient 'gyptian treatise the
'dwin Smith Surgical Papyrus (circa )***+,-** BC." and /ippocrates0 writings in the 1th century contain
a series of trauma case reports! including thoracic injuries.
Morbidity and mortality
Trauma is the leading cause of death! morbidity! hospitali2ation! and disability in &mericans aged , year
to the middle of the fifth decade of life. &s such! it constitutes a major health care problem. &ccording to
the Centers for 3isease Control and Prevention! appro4imately ,,5!*** accidental deaths occurred in the
United States in 6**1.(,.
Frequency
Trauma is responsible for more than ,**!*** deaths annually in the United States.(,. 'stimates of
thoracic trauma fre$uency indicate that injuries occur in ,6 persons per million population per day.
&ppro4imately ))7 of these injuries re$uire hospital admission. 8verall! blunt thoracic injuries are directly
responsible for 6*+617 of all deaths! and chest trauma is a major contributor in another 1*7 of deaths.
Etiology
By far! the most important cause of significant blunt chest trauma is motor vehicle accidents 9:&s".
9:&s account for ;*+5*7 of such injuries. &s a result! preventive strategies to reduce 9:&s have been
instituted in the form of speed limit restriction and the use of restraints. Pedestrians struck by vehicles!
falls! and acts of violence are other causative mechanisms. Blast injuries can also result in significant
blunt thoracic trauma.
Pathophysiology
The major pathophysiologies encountered in blunt chest trauma involve derangements in the flow of air!
blood! or both in combination. Sepsis due to leakage of alimentary tract contents! as in esophageal
perforations! also must be considered.
Blunt trauma commonly results in chest wall injuries eg! rib fractures". The pain associated with these
injuries can make breathing difficult! and this may compromise ventilation.
3irect lung injuries! such as pulmonary contusions see the image below"! are fre$uently associated with
major chest trauma and may impair ventilation by a similar mechanism.
<eft pulmonary contusion following a motor vehicle accident involving a pedestrian.
Shunting and dead space ventilation produced by these injuries can also impair o4ygenation.
Space+occupying lesions! such as pneumothoraces! hemothoraces! and hemopneumothoraces! interfere
with o4ygenation and ventilation by compressing otherwise healthy lung parenchyma. & situation of
special concern is tension pneumothora4 in which pressure continues to build in the affected hemithora4
as air leaks from the pulmonary parenchyma into the pleural space. This can push mediastinal contents
toward the opposite hemithora4. 3istortion of the superior vena cava by this mediastinal shift can result in
decreased blood return to the heart! circulatory compromise! and shock.
&t the molecular level! animal e4perimentation supports a mediator+driven inflammatory process further
leading to respiratory insult after chest trauma. =ollowing blunt chest trauma! several blood+borne
mediators are released! including interleukin+-! tumor necrosis factor! and prostanoids. These mediators
are thought to induce secondary cardiopulmonary changes. Blunt trauma that causes significant cardiac
injuries eg! chamber rupture" or severe great vessel injuries eg! thoracic aortic disruption" fre$uently
results in death before ade$uate treatment can be instituted. This is due to immediate and devastating
e4sanguination or loss of cardiac pump function. This causes hypovolemic or cardiogenic shock and
death.
Sternal fractures are rarely of any conse$uence! e4cept when they result in blunt cardiac injuries.
Clinical
The clinical presentation of patients with blunt chest trauma varies widely and ranges from minor reports
of pain to florid shock. The presentation depends on the mechanism of injury and the organ systems
injured.
8btaining as detailed a clinical history as possible is e4tremely important in the assessment of a patient
with a blunt thoracic trauma. The time of injury! mechanism of injury! estimates of 9:& velocity and
deceleration! and evidence of associated injury to other systems eg! loss of consciousness" are all
salient features of an ade$uate clinical history. #nformation should be obtained directly from the patient
whenever possible and from other witnesses to the accident if available.
=or the purposes of this discussion! the authors divide blunt thoracic injuries into ) broad categories as
follows> ," chest wall fractures! dislocations! and barotrauma including diaphragmatic injuries"? 6" blunt
injuries of the pleurae! lungs! and aerodigestive tracts? and )" blunt injuries of the heart! great arteries!
veins! and lymphatics. & concise e4egesis of the clinical features of each condition in these categories is
presented. This classification is used in subse$uent sections to outline indications for medical and
surgical therapy for each condition.
Approach Considerations
#nitial emergency workup of a patient with multiple injuries should begin with the &BCs of trauma! with
appropriate intervention taken for each step.
Laboratory Studies
CBC count
& CBC count is a routine laboratory test for most trauma patients. The CBC count helps gauge blood loss!
although the accuracy of findings to help determine acute blood loss is not entirely reliable. 8ther
important information provided includes platelet and white blood cell counts! with or without differential.
&rterial blood gas
&rterial blood gas &B@" analysis! though not as important in the initial assessment of trauma victims! is
important in their subse$uent management. &B@ determinations are an objective measure of ventilation!
o4ygenation! and acid+base status! and their results help guide therapeutic decisions such as the need for
endotracheal intubation and subse$uent e4tubation.
Serum chemistry profile
Patients who are seriously injured and re$uire fluid resuscitation should have periodic monitoring of their
electrolyte status. This can help to avoid problems such as hyponatremia or hypernatremia. The etiology
of certain acid+base abnormalities can also be identified! eg! a chloride+responsive metabolic alkalosis or
hyperchloremic metabolic acidosis.
Coagulation profile
The coagulation profile! including prothrombin timeAactivated partial thromboplastin time! fibrinogen! fibrin
degradation product! and 3+dimer analyses! can be helpful in the management of patients who receive
massive transfusions eg! B,* U packed %BCs". Patients who manifest hemorrhage that cannot be
e4plained by surgical causes should also have their profile monitored.
Serum troponin levels
The rate of cardiac injury in patients with blunt chest trauma varies widely depending upon the diagnostic
criteria. Troponin is a protein specific to cardiac cells. Chile elevated serum troponin # levels correlate with
the presence of echocardiographic or electrocardiographic abnormalities in patients with significant blunt
cardiac injuries! these levels have low sensitivity and predictive values in diagnosing myocardial
contusion in those without. &s such! troponin # level determination does not! by itself! help predict the
occurrence of complications that may re$uire admission to the hospital. &ccordingly! their routine use in
this clinical situation is not well supported.(6! ).
Serum myocardial muscle creatine kinase isoen2yme levels
9easurement of serum myocardial muscle creatine kinase isoen2yme creatine kinase+9B" levels is
fre$uently performed in patients with possible blunt myocardial injuries. The test is rapid and ine4pensive.
This diagnostic modality has recently been critici2ed because of poor sensitivity! specificity! and positive
predictive value in relation to clinically significant blunt myocardial injuries.
Serum lactate levels
<actate is an end product of anaerobic glycolysis and! as such! can be used as a measure of tissue
perfusion. Cell+perfused tissues mainly use aerobic glycolytic pathways. Persistently elevated lactate
levels have been associated with poorer outcomes. Patients whose initial lactate levels are high but are
rapidly cleared to normal have been resuscitated well and have better outcomes.
Blood type and crossmatch
Type and crossmatch are some of the most important blood tests in the evaluation and management of a
seriously injured trauma patient! especially one who is predicted to re$uire major operative intervention.
Imaging Studies
Chest radiographs
The chest radiograph CD%" is the initial radiographic study of choice in patients with thoracic blunt
trauma. & chest radiograph is an important adjunct in the diagnosis of many conditions! including chest
wall fractures! pneumothora4! hemothora4! and injuries to the heart and great vessels eg! enlarged
cardiac silhouette! widened mediastinum".
#n contrast! certain cases arise in which physicians should not wait for a chest radiograph to confirm
clinical suspicion. The classic e4ample is a patient presenting with decreased breath sounds!
hyperresonant hemithora4! and signs of hemodynamic compromise ie! tension pneumothora4". This
should be immediately decompressed before obtaining a chest radiograph.(E.
& 6*,6 study by Paydar et al indicated that routine chest radiography in stable blunt trauma patients may
be of low clinical value. The authors propose that careful physical e4amination and history taking can
accurately identify those patients at low risk for chest injury! thus making routine radiographs
unnecessary.(1.
Chest CT scan
3ue to lack of sensitivity of chest radiography to identify significant injuries! computed tomography CT"
scan of the chest is fre$uently performed in the trauma bay in the hemodynamically stable patient. #n one
study! 1*7 of patients with normal chest radiographs were found to have multiple injuries on chest CT
scan. &s a result! obtaining a chest CT scan in a supposedly stable patient with significant mechanism of
injury is becoming routine practice.
/elical CT scanning and CT angiography CT&" are being used more commonly in the diagnosis of
patients with possible blunt aortic injuries. 9ost authors advocate that positive findings or findings
suggestive of an aortic injury eg! mediastinal hematoma" be augmented by aortography to more
precisely define the location and e4tent of the injury.(-! ;! 5.
&bdominal CT alone or combined with cervical spinal CT detected almost all occult small
pneumothoraces in one study of patients with blunt trauma! while cervical spinal CT alone detected only a
third of cases.(F.
&ortogram
&ortography has been the criterion standard for diagnosing traumatic thoracic aortic injuries. /owever! its
limited availability and the logistics of moving a relatively critical patient to a remote location make it less
desirable. #n addition! with the new generation spiral CT scanners! which have ,**7 sensitivity and
greater than FF7 specificity! the role of aortography in the evaluation of trauma patients is declining.
/owever! where spiral CT is e$uivocal! aortography can provide a more e4act delineation of the location
and e4tent of aortic injuries. &ortography is much better at demonstrating injuries of the ascending aorta.
#n addition! it is superior at imaging injuries of the thoracic great vessels.(,*! ,,.
Thoracic ultrasound
Ultrasound e4aminations of the pericardium! heart! and thoracic cavities can be e4peditiously performed
by surgeons and emergency department '3" physicians within the '3. Pericardial effusions or
tamponade can be reliably recogni2ed! as can hemothoraces associated with trauma. The sensitivity!
specificity! and overall accuracy of ultrasound in these settings are all more than F*7.
Contrast esophagogram
Contrast esophagograms are indicated for patients with possible esophageal injuries in whom
esophagoscopy results are negative. The esophagogram is first performed with water+soluble contrast
media. #f this provides a negative result! a barium esophagogram is completed. #f these results are also
negative! esophageal injury is reliably e4cluded.
'sophagoscopy and esophagography are each appro4imately 5*+F*7 sensitive for esophageal injuries.
These studies are complementary and! when performed in se$uence! identify nearly ,**7 of esophageal
injuries.
=ocused &ssessment for the Sonographic '4amination of the Trauma Patient
The =ocused &ssessment for the Sonographic '4amination of the Trauma Patient =&ST" is routinely
conducted in many trauma centers. &lthough mainly dealing with abdominal trauma! the first step in the
e4amination is to obtain an image of the heart and pericardium to assess for evidence of intrapericardial
bleeding.
iagnostic !ests and Procedures
Twelve+lead electrocardiogram
The ,6+lead electrocardiogram 'C@" is a standard test performed on all thoracic trauma victims. 'C@
findings can help identify new cardiac abnormalities and help discover underlying problems that may
impact treatment decisions. =urthermore! it is the most important discriminator to help identify patients
with clinically significant blunt cardiac injuries.
Patients with possible blunt cardiac injuries and normal 'C@ findings re$uire no further treatment or
investigation for this injury. The most common 'C@ abnormalities found in patients with blunt cardiac
injuries are tachyarrhythmias and conduction disturbances! such as first+degree heart block and bundle+
branch blocks.
Transesophageal echocardiography
Transesophageal echocardiography T''" has been e4tensively studied for use in the workup of possible
blunt rupture of the thoracic aorta. #ts sensitivity! specificity! and accuracy in the diagnosis of this injury are
each appro4imately F)+F-7. #ts advantages include the easy portability! no re$uisite contrast! minimal
invasiveness! and short time re$uired to perform. T'' can also be used intraoperatively to help identify
cardiac abnormalities and monitor cardiac function.(,6! ,)! ,E.
The disadvantages include operator e4pertise! long learning curve! and the fact that it is relatively weak at
helping identify injuries of the descending aorta.
Transthoracic echocardiography
Transthoracic echocardiography TT'" can help identify pericardial effusions and tamponade! valvular
abnormalities! and disturbances in cardiac wall motion. TT's are also performed in cases of patients with
possible blunt myocardial injuries and abnormal 'C@ findings.
=le4ible or rigid esophagoscopy
'sophagoscopy is the initial diagnostic procedure of choice in patients with possible esophageal injuries.
'ither fle4ible or rigid esophagoscopy is appropriate! and the choice depends on the e4perience of the
clinician. Some authors prefer rigid esophagoscopy to evaluate the cervical esophagus and fle4ible
esophagoscopy for possible injuries of the thoracic and abdominal esophagus. #f esophagoscopy findings
are negative! esophagography should be performed as outlined above.
=iberoptic or rigid bronchoscopy
=iberoptic or rigid bronchoscopy is performed in patients with possible tracheobronchial injuries. Both
techni$ues are e4tremely sensitive for the diagnosis of these injuries. =iberoptic bronchoscopy offers the
advantage of allowing an endotracheal tube to be loaded onto the scope and the endotracheal intubation
to be performed under direct visuali2ation if necessary.