Initial Management for Thoracic Trauma

The most important early priority in the treatment of a patient with thoracic trauma is assessment and treatment for injuries that may be immediately life-threatening (listed below). Tube thoracostomy is often indicated in a severely injured thoracic trauma patient, and will generally provide useful clinical information (and potential treatment) regardless of diagnosis.

Tension Pneumothorax

1. Clinical suspicion of tension pneumothorax requires rapid treatment, either with needle decompression and subsequent tube thoracostomy, or with immediate tube thoracostomy. The choice between these two alternatives depends on the immediate availability of thoracostomy supplies, the patient’s condition, and the experience of the person performing the procedure.
2. Needle decompression should be performed with a large bore (14 gauge or larger) 3.25in/8cm catheter in the 4th or 5th intercostal space, anterior axillary line. The alternate needle decompression site is the 2nd intercostal space at the mid-clavicular line (this is the primary site in children). Ensure dedicated needle decompression catheters are available with all emergency medical supplies; shorter (5cm) catheters used for venous access should be avoided as these will rarely penetrate the thoracic cavity and thus be ineffective.
3. Needle decompression alone is insufficient treatment for a pneumothorax and certainly ineffective for hemothorax and should in most cases be followed by placement of a tube thoracostomy as soon as feasible and safe. For stable patients who have undergone needle thoracostomy, evaluation with ultrasound or chest X-ray to assess the need for chest tube placement is appropriate.
4. If tube thoracostomy placement is delayed, providers should be prepared to repeat needle decompression as needed. Failure to improve after two needle decompressions most likely indicates an alternative diagnosis to pneumothorax (e.g., hemothorax, pulmonary contusion, and diaphragm injury).
5. Tube thoracostomy is performed using blunt/open technique, as described in Appendix A: Specific Thoracic Procedures.

Open Pneumothorax

Initial management with placement of a vented chest seal is reasonable until a tube thoracostomy can be performed.

Massive Hemothorax

1. The return of blood under pressure or a large volume of blood after tube thoracostomy indicates significant intra-thoracic injury.
2. Parenchymal lung injuries are the most common source of hemothorax, but massive hemothorax is likely due to a chest wall vascular injury, hilar pulmonary injury, or great vessel/cardiac injury.
3. With the immediate return of 1,500ml of blood after tube thoracostomy, thoracotomy is indicated. When the initial blood loss is below 1,500mL but significant bleeding continues (more than 200-250ml/hr and/or ongoing transfusion requirements), thoracotomy is also indicated.
4. In a patient with hemothorax due to penetrating injury and loss (or impending loss) of vital signs during or immediately prior to arrival, emergency resuscitative thoracotomy is indicated. (See the JTS Emergency Resuscitative Thoracotomy CPG.8)
5. All patients with massive hemothorax will require damage control resuscitation and massive blood product transfusion (as outlined in respective CPGs).
6. Anterolateral thoracotomy is the best approach for massive hemothorax in an acute trauma patient. Although a posterolateral thoracotomy (ideally with lung isolation) may provide more optimal exposure, it presents limitations if additional incisional exposure is needed, may place the contralateral lung at risk for aspiration, and requires positioning maneuvers that may be challenging in a bleeding, acutely injured patient.
7. If after ipsilateral anterolateral thoracotomy, an intra-pericardial injury is encountered, conversion to a clamshell (bilateral thoracosternotomy) incision (described below) is indicated.
8. If a proximal left subclavian injury is encountered after left anterolateral thoracotomy, conversion to a trapdoor incision (described below) is an option to improve exposure.
9. In patients with penetrating trauma to the torso, a high suspicion must be maintained for bleeding in the other body cavities (opposite chest or abdomen).
10. Autotransfusion of shed pleural blood using a chest tube collection system and autotransfusion accessory can be considered.9

Suspected Cardiac or Great Vessel Injury

1. Cardiac tamponade due to combat trauma requires immediate surgical intervention.
2. Fluid resuscitation may temporarily stabilize a patient in tamponade.
3. Pericardiocentesis (ultrasound guided, if available) combined with blood transfusion may help temporize a patient until arrival to a surgical capability,10 recognizing that blood re-accumulation is likely.
4. Patients with suspected isolated great vessel injury (contained mediastinal hematoma) should receive pain control. If hemodynamics allow, this should be followed by a short-acting beta blocker (e.g., esmolol drip) to prevent tachycardia and hypotension.

Rib Fractures, Flail Chest

1. In the absence of associated massive or ongoing bleeding into the pleural space, there is no role for surgical intervention for blunt chest wall injury. The major clinical significance of blunt chest wall injury in most cases is the potential for associated contusion of the underlying lung, which can have a major detriment on oxygenation and pulmonary status.
2. If physical exam or chest X-ray suggests the possibility of pneumothorax or hemothorax, immediate tube thoracostomy is indicated. In cases where clinical or radiographic findings are equivocal, clinicians should err on the side of tube thoracostomy prior to transport.
3. The treatment of rib fractures and flail chest includes pain control, close monitoring, oxygenation and ventilatory support as needed. Consider local and regional anesthetics in addition to systemic pain medications.

Thoracic Tracheobronchial Injury

1. Initial management is aimed at ensuring adequate oxygenation and ventilation.
2. Tube thoracostomy is an important early intervention. If negative pressure suction through a tube thoracostomy worsens respiratory function due to a large air leak, the tube should be taken off of suction and placed to water seal. An alternative is connecting the chest tube to a one-way Heimlich valve.
3. If one chest tube does not re-inflate the lung, then a second chest tube should be placed.
4. Advancing an endotracheal tube into the right mainstem bronchus may help manage a significant tidal volume loss from left-sided injuries.
5. Other maneuvers, when available, include the use of bronchial blockers or double lumen endotracheal tube.

Extra Corporeal Membrane Oxygenation (ECMO)

1. ECMO may allow oxygenation for problematic injuries, and the DoD ECMO team should be contacted early if this is considered. For ECMO referrals 24/7 contact: (210) 916-ECMO/DSN (312) 429-ECMO (leave message if not answered immediately); alternate contact SAMMC operator at (210) 916-2500/DSN (312) 429-2500. DoD ECMO team members can also be reached by email at: usarmy.jbsa.medcom-bamc.list.ecmo@health.mil.
2. For specific ECMO indications, refer to the JTS Acute Respiratory Failure CPG.11