Management of thoracic trauma
Blunt Thoracic Trauma

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Blunt thoracic trauma represents a significant portion of trauma admissions to hospitals in the United States. These injuries are encountered by physicians in many specialities such as emergency medicine, pediatrics, general surgery and thoracic surgery. Accurate diagnosis and treatment improves the chances of favorable outcomes and it is desirable for all treating physicians to have current knowledge of all aspects of blunt thoracic trauma. Cardiothoracic surgeons often treat the most severe forms of blunt thoracic injuries and we review the aspects of blunt thoracic trauma that are pertinent to the practicing cardiothoracic surgeon.

Section snippets

Blunt Cardiac Injury

Cardiac trauma after blunt chest injury has been reported to occur in up to 76% of patients.5, 6 The term blunt cardiac injury (BCI) refers to a spectrum of sequelae from blunt trauma that ranges from imperceptible to fatal, and is directly related to the level of force applied during the injury.5, 7 The accurate diagnosis of these injuries is challenging and is partly due to a lack of well defined criteria. The majority of blunt cardiac injuries occur as a result of motor vehicle accidents but

Electrocardiography Evaluation

There appears to be universal agreement that an initial electrocardiogram (ECG) be performed on every patient with suspected blunt cardiac injury.8, 9, 10, 11, 12 The most common ECG abnormality seen in blunt cardiac injury is sinus tachycardia followed by premature atrial or ventricular contractions (PAC, PVC).7 An initial abnormal ECG in blunt chest trauma patients has been reported to be a significant predictor of cardiac complications due to blunt injury.9, 11 Foil and coworkers reported

Myocardial Enzyme Release

The release of creatinine kinase (CK) with myocardial specific (MB) fractions occurs as a result of myocardial contusion, which is characterized by muscle necrosis, edema, and hemorrhagic infiltrates.7 The measurement of this enzyme in the setting of blunt cardiac injury has been reported as a method of identifying patients with BCI.5, 13, 14 Several authors have described experience using this diagnostic technique with the general conclusions being that although the measurement of CK-MB may

Echocardiography

Echocardiography is a useful tool in evaluating structural abnormalities of the heart, and can be very useful in the evaluation and treatment of patients with suspected blunt cardiac injury.18 Abnormalities in wall motion, valvular disruption, and pericardial effusions can all be readily detected using echocardiography, and can significantly alter management of patients.7 However, the routine use of echocardiography in all patients with suspected blunt trauma should be discouraged as there is

Commotio Cordis

Commotio cordis (CC) is defined as sudden death produced as a result of a direct blow to the chest. The exact etiology of death is unclear but it is often presumed that the direct blow induces ventricular fibrillation.21 This entity is often the result of innocuous appearing trauma but is being reported with increasing frequency. This is likely due to its recognized association with victims of young age and competitive sports, baseball being the most common. Aims at prevention of commotio

Great Vessel and Thoracic Aortic Injury

Approximately 7,500 to 8,500 cases of blunt aortic injury or rupture occur each year in the United States.23 Eighty-five to 90% of these patients will die at the accident scene.23, 24 Twenty-five percent of patients who survive transport to the hospital will not live.24 Blunt aortic injury is second only to head trauma as a cause of death after blunt trauma.

It is suggested that three groups of patients exist who undergo blunt aortic injury: those who die at the scene (70% to 80% of the whole);

Lungs and Pleura

Lung injury after blunt trauma represents a wide spectrum of sequelae with pulmonary contusion being the most common. This entity is most commonly managed with nonoperative techniques and is thoroughly covered in other sections of this review.1

Lung injury in the form of lacerations from fractured ribs, deceleration injuries producing pulmonary vascular injuries, and barotrauma from compressive injuries can injure the lung parenchyma with varying severity.4 Lung injury requiring operative repair

Retained Hemothorax

Both life-threatening and less critical blunt chest injuries often result in the introduction of blood into the pleural space. The finding of a hemothorax or hemopneumothorax is most often followed by tube thoracostomy drainage of the respective pleural space. Drainage of the hemothorax by tube thoracostomy is incomplete in approximately 5% of patients.29 This may lead to the complications of empyema and fibrothorax, both of which may lead to more complex surgical procedures and potentially

Pneumothorax

Pneumothorax is very common after blunt chest injury, occurring in up to 25% of patients. The recognition of the diagnosis of pneumothorax is potentially life saving but is not recognized in up to 30% of patients in the prehospital setting despite auscultation. The reason for this is likely due to the frequent presence of associated injuries, which may distract the caregiver. Pneumothorax is most often produced by puncture by fractured ribs or by compression and shear forces. Treatment by tube

Blunt Traumatic Diaphragmatic Rupture

Diaphragmatic injury after blunt trauma is reported to occur in up to 8% of patients and is most often the result of vehicular accidents. The majority of diaphragmatic injuries are left sided and may be due to the protection that the liver affords the right side.1, 32 The diaphragm is rarely the only organ injured after blunt trauma and its presence is thought to be a marker for other possibly more severe injuries.33 Frequently associated injuries include splenic laceration, rib fractures,

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