Target Patient Population: All patients with chest injury of AIS code 2 or greater.

Intent (Expected Outcomes)

1. Tube thoracostomy will be used early in the management of any patient with penetrating chest trauma or suspected hemothorax, pneumothorax.
2. Needle decompression or tube thoracostomy is done for tension pneumothorax.
3. Ultrasound exam is used for patients with suspicion of cardiac injury, followed by sternotomy for exploration and repair if positive.
4. Patients with massive hemothorax > 1,500 ml are treated with thoracotomy at the first surgical capability.
5. Acute chest trauma requiring surgical intervention is treated by anterolateral thoracotomy, clamshell thoracotomy or median sternotomy as the appropriate initial approaches for acute chest trauma.
6. When chest and abdominal injury are suspected, the initial approach is tube thoracostomy (unilateral or bilateral depending on injury pattern) and laparotomy.

Performance/Adherence Measures

1. In any patient with penetrating chest injury, or with clinical or radiological diagnosis of hemo- or pneumothorax, a tube thoracostomy is placed prior to transport from the first surgical capability.

The primary adherence measure is the percentage of patients with penetrating chest injury or diagnosed hemo- or pneumothorax who had a tube thoracostomy placed prior to transport from the first surgical capability.

1. In patients who receive needle decompression of the chest, the specific reason that tension pneumothorax was suspected is documented.
2. When pericardial tamponade is diagnosed by a surgical team, the initial incision is sternotomy or a specific reason for anterolateral or clamshell thoracotomy is documented (e.g., absent pulses).
3. For patients who undergo thoracotomy or sternotomy at the first surgical capability, the indication for the procedure is clearly documented.
4. In chest trauma patients with SBP < 90 or massive hemothorax > 1,500 ml or ongoing bleeding from chest tubes who undergo surgery, anterolateral thoracotomy or sternotomy is the initial incision.

Within the subset of thoracic trauma patients with SBP < 90, a secondary adherence measure is the percentage of these patients who received anterolateral thoracotomy or sternotomy.

1. In the subset of patients with penetrating chest trauma and abdominal injury, the initial approach is tube thoracostomy (unilateral or bilateral depending on injury pattern) and laparotomy.

Within these patients, a secondary adherence measure will be the percentage of patients with both a penetrating chest injury and abdominal injury who received a laparotomy and tube thoracostomy.

1. If ultrasound is available, E-FAST results are documented in all patients with significant chest injury (AIS code 2 or greater).

Data Sources

- Patient Record
- Department of Defense Trauma Registry (DoDTR)

System Reporting & Frequency

The above constitutes the minimum criteria for PI monitoring of this CPG. System reporting will be performed annually; additional PI monitoring and system reporting may be performed as needed.

The system review and data analysis will be performed by the Joint Trauma System (JTS) Director, JTS Program Manager, and the JTS Performance Improvement Branch.