Injuries may be classified according to the site(s) and mechanism(s) of injury. Abdominal and thoracic trauma can be classified according to site as skeletal, pulmonary, heart and great vessels, visceral or diaphragmatic injury; and the mechanisms may be blunt or penetrating injury types. Blunt injuries result from forces distributed over a relatively large area and include deceleration or compression injuries. With penetrating injuries, forces are generally distributed over a small area and the organs injured are usually those that lie along the path of the penetrating object.

Abdominal or thoracic injuries, in the form of blunt or penetrating trauma, are often caused by falls from a height, motor vehicle and motor cycle crashes, pedestrian vehicle crashes, violence or attempted suicide. The epidemiology of thoracic and abdominal trauma varies according to social, economic, cultural and geographical characteristics (Herrera and Langer, 2008). A positive blood alcohol level and the use of drugs remain the highest risk factors for motor cycle, motor vehicle and pedestrian vehicle crashes, as well as for intentional injury caused to others or oneself (Carrasco et al., 2012; Brady and Li, 2013). Children are particularly vulnerable to trauma due to their physical size (smaller bodies result in a greater distribution of force), improper restraining in motor vehicles and issues of neglect or overt violence or abuse (Van As, 2010).

Damage caused to the trunk by a penetrating object depends on the shape, size and velocity of the object, as well as the distance between the object and the person. The severity of a bullet injury is directly proportional to the amount of kinetic energy that is delivered to the tissues. The mortality associated with gunshot wounds is eight times higher than that of stab wounds (De Groot and Van Oppell, 2003).

High-velocity wounds can be caused by fragments of explosive devices such as grenades, bombs or high-velocity bullets from machine guns or rifles. High-velocity bullets cause damage to tissues in the path of the bullet, but also to remote organs. Shock waves radiate from the missile tract through the tissues, forcing them to accelerate violently forwards and outwards. A large cavity is formed that is larger than the diameter of the missile (Maiden, 2009; Hauer et al., 2011). This creates a vacuum that sucks debris, air and bacteria from the external environment into the primary missile tract and the cavity collapses over a period of a few milliseconds. Blood vessel and nerve damage, as well as shattering of bones, may result without these structures being directly hit by the bullet (Feliciano, 2004; Maiden, 2009; Hauer et al., 2011).

Penetrating abdominal and thoracic trauma is much less common than blunt trauma in the paediatric age group (Kadish, 2006; Saladina and Lund, 2006). However, the incidence of gunshot and stab injuries in children and adolescents is increasing at alarming rates in the US and South Africa (Prinsloo et al., 2012; Schecter et al., 2012), with unchanged rates of injury reported from the United Kingdom (Melling et al., 2012).

The size of an abdominal organ and its contact with the anterior abdominal wall determine the frequency with which the organ is wounded. The most commonly injured organs are the abdomen, liver, small bowel (most commonly) and the colon (Feliciano, 2003; Thomson, 2003). Abdominal vascular injuries are common following penetrating trunk trauma. Abdominal injuries may accompany chest wounds or vice versa (Feliciano, 2003; Thomson, 2003).

Penetrating abdominal injuries are not immediately life threatening unless a major blood vessel is damaged. Stab wounds to the abdomen are easier to manage than those to the chest and involve injury to the major abdominal vasculature only 10% of the time (Feliciano, 2003). Stab wounds to the back are often accompanied by abdominal injuries. A gunshot wound that penetrates a major artery or vein and the colon is potentially lethal, initially due to haemorrhage and subsequently due to sepsis through the possible contamination of either the vascular wound repair site or the peritoneum (Feliciano, 2004).

Abdominal injuries affect 10–15% of injured children, with the spleen being the most affected organ (Gaines, 2009). Abdominal injuries are a marker of severe trauma in children (Coppola and Gilbert, 2011).

The severity of injury resulting from thoracic trauma relates to the fundamental importance of the organs and physiological systems situated within the thoracic cavity.

Blunt thoracic trauma involves injuries such as fractured ribs, haemothorax, pneumothorax and pulmonary contusion. High-speed deceleration trauma may lead to cardiac, aortic, diaphragmatic and bronchial injuries. Myocardial contusion may accompany up to 76% of blunt thoracic injuries and, if diagnosed quickly, has a low mortality rate (Bansal et al., 2005). Diaphragmatic rupture occurs in less than 10% of victims of motor vehicle accidents. The left hemi-diaphragm ruptures more frequently than the right hemi-diaphragm, which is protected by the liver (Chughtai et al., 2009).

Penetrating injuries of the chest are the most lethal of injuries. The site and size of the wound to the chest wall determines the condition of the patient. The patient’s capacity to ventilate depends on the subsequent ability to sustain a negative intrapleural pressure (due to air leak from the lung into the pleural space), the extent of the parenchymal injury and oxygen delivery to the tissues (ventilation/perfusion (V/Q) ratio) (De Groot and Van Oppell, 2003). Pneumothoraces, lung collapse, diaphragmatic rupture and cardiovascular injury may all contribute to severe respiratory distress, which can be life threatening if left unattended (Livingstone and Hauser, 2004).

On-scene fatality due to traumatic injuries is high in the adult population. Death at the scene is greater with high-energy injuries (motor cycle, motor vehicle or pedestrian vehicle accidents; falls from a height; gunshot or stab injuries) than low-energy injuries (falls from low height), and mostly occurs due to traumatic brain injuries, high-level spinal cord injuries or severe blood loss from injury to the great vessels. In-hospital deaths in adults after trauma-related injuries are usually as a result of hypotension, respiratory distress or low admission Glasgow coma score (GCS) (less than eight) (Søreide et al., 2007; Evans et al., 2010).

In-hospital complications of thoracic and abdominal injuries may arise from impairment of cardiac output or gaseous exchange. Impaired cardiac output occurs due to blood loss, increased intrapleural pressures, blood in the pericardial sac, myocardial valve damage or vascular disruption. Impaired gaseous exchange develops due to atelectasis, contused lung tissue or disruption of the respiratory tract. Thoracic trauma contributes to mortality in a quarter of trauma-related deaths (Zargar et al., 2007; Oikonomou and Prassopoulos, 2011). The mortality rate increases in proportion to the time between injury and surgery (Adesanya et al., 2000). Multiple organ failure is a common cause of late-hospital fatality (Søreide et al., 2007; Evans et al., 2010).

The medical and surgical management of any patient with traumatic injury is divided into:

The specific management of patients with abdominal or thoracic injuries is outlined below in relation to the abovementioned three phases of care.

On admission to the emergency department, initial assessment and management of the adult and paediatric patient focuses on identifying and reversing hypoxia, which is the most serious problem. Assessment for injuries that are life threatening is also done during the primary survey. Internationally, the ‘airways, breathing, circulation, disability, exposure’ (ABCDE) approach to basic life support is used for all adult and paediatric patients with trauma-related injuries admitted to casualty (Thim et al., 2012).

During the primary survey, ABCDE are all assessed, regardless of the organ system damaged. The ABCDE approach consists of assessment for (Thim et al., 2012) the following.

Children with thoracic or abdominal injuries may present in respiratory or circulatory failure, but respiratory failure is more common with signs of tachypnoea, chest wall recessions or retractions and agitation secondary to hypoxia (Kadish, 2006).

Radiological investigations such as ultrasound technology, chest x-rays and computed tomography (CT) scans form part of the primary survey in order to identify life-threatening injuries that are not visible. Particularly in paediatric populations, ultrasound is extensively used in the diagnosis of thoracic and abdominal dysfunction and has the advantages of non-invasiveness and lack of radiation (Gaines, 2009). Diagnostic peritoneal lavage (DPL) may also be performed, if indicated, to diagnose intra-peritoneal haemorrhage.

This is managed by positioning the patient’s head and neck to open the airway (with protection of the cervical spine) and suctioning to remove obstructions such as blood or vomit. Foreign bodies causing obstruction should be removed if possible. The insertion of an artificial airway may be indicated for an unconscious patient (Thim et al., 2012).

Blood in the pericardial sac, usually resulting from penetrating injuries, prevents cardiac activity. The patient may present with ‘Beck’s triad’ which constitutes:

Furthermore, there may be ‘pulsus paradoxus’: a decrease of 10 millimetres of mercury (mmHg) or greater in systolic blood pressure (BP) during inspiration. A systolic to diastolic gradient of greater than 30 mmHg is also suggestive of cardiac tamponade. Diagnosis is confirmed through the use of extended FAST (Rippey and Royse, 2009). Emergency treatment is the removal of a small amount of blood from the pericardial sac.

The secondary survey also takes place in the emergency department. It begins after the completion of the primary survey, when resuscitation has been carried out and vital functions normalised. The secondary survey is a ‘head-to-toe’ evaluation of the patient, which involves taking a detailed history of the patient as well as a complete neurological and physical examination.

Care provided to the patient during the primary survey continues in the secondary survey. If the patient’s condition is stable, placement of arterial and central venous pressure (CVP) lines are performed. If the patient’s condition is unstable, placement of these lines is done in theatre or in the intensive care unit (ICU) as part of definitive care.

The secondary survey is guided by suspicion for injuries missed during the primary survey, especially in patients who are unconscious or unstable. The presence of possible abdominal injury should be confirmed, as serious complications can occur in both adults and children if diagnosis is delayed.

Pulmonary contusion refers to injury of the lung parenchyma without laceration. It is a potentially life-threatening condition with an insidious onset, and is particularly common in children (Kadish, 2006). Interstitial haemorrhage and oedema fluid that result from the contusion leak into the alveoli and cause reduced pulmonary compliance, atelectasis (exacerbated by decreased surfactant production by injured alveolar cells) and hypoventilation. Bronchospasm may result from bleeding into lung segments that were not affected at the time of injury and this leads to further pulmonary dysfunction. Pulmonary dysfunction may also be compromised by increased mucus production and decreased clearance of mucus (Cohn and DuBose, 2010). More than 50% of adults and 20% of children will develop pneumonia, even with treatment (Bliss and Silen, 2002; Tovar, 2008).

Myocardial or cardiac contusions occur as a result of blunt precordial chest trauma and are often difficult to diagnose. There is a risk of dysrhythmias, tamponade, pericarditis and sudden death. Myocardial contusion is diagnosed by ECG and elevated cardiac-specific enzyme levels. Blunt cardiac injury is rare in children, occurring in less than 5% of paediatric trauma patients (Taio et al., 2000; Kadish, 2006).

This type of injury is associated with rapid deceleration-type accidents. It is associated with high mortality at the accident scene, and for those who survive to hospital, mortality increases significantly with each undiagnosed day. Disruption occurs at the ligamentum arteriosum (ductus arteriosus) and results in a contained haematoma of 500–1000 ml of blood. Specific radiographic signs include a widened mediastinum, tracheal and oesophageal deviation to the right, and first and second rib fractures. Definitive surgical repair is required (O’Connor et al., 2009).

Great vessel and cardiac injuries are much less common in children than in adults (Bliss and Silen, 2002; Kadish, 2006). However, more than 80% of children who sustain an aortic tear will also have significant injuries to the lung, heart, abdominal viscera and nervous system, and there is a high associated mortality (Bliss and Silen, 2002; Kadish, 2006).

Diaphragmatic tears lead to immediate or delayed visceral herniation and lung compression. Left-sided hemi-diaphragm rupture is more common than right-sided hemi-diaphragm rupture in adults due to the protection provided by the liver (Chughtai et al., 2009; Vilallonga et al., 2011).

In children, diaphragmatic rupture occurs in up to 5% of cases following major chest trauma, particularly blunt trauma. The site of rupture is usually posterolateral (Chughtai et al., 2009; Moore et al., 2009). Surgical repair is the definitive treatment.

Tracheobronchial injury refers to injury involving the larynx, trachea or bronchus. Injury to the larynx is rare. Suspicion is raised if the patient presents with hoarseness of the voice or subcutaneous emphysema and intubation proves to be difficult. Tracheal injury may be accompanied by oesophageal injury. Bronchial injury, usually due to blunt trauma, is rare and may be lethal. Injuries to the tracheobronchial tree are rare in children, but may occur following both penetrating and blunt trauma and are associated with up to 30% mortality (Bliss and Silen, 2002; Tovar, 2008). Up to 80% of all paediatric airway injuries occur in the distal trachea or bronchi. Most injuries show mediastinal air, although more distal injuries may present with pneumothoraces (Bliss and Silen, 2002; Kadish, 2006).

This is commonly caused by penetrating injury and may be lethal if not recognised. A high suspicion of oesophageal trauma is raised if the patient has a left pneumothorax and haemothorax without rib fractures. Another cause for concern is the presence of shock out of proportion to apparent blunt chest trauma, and there may be particulate matter in the ICD tube (Bliss and Silen, 2002). Oesophageal injuries are rare in children and are difficult to diagnose. Oesophageal perforation in children is mostly caused by iatrogenic injury followed by penetrating trauma and may have devastating consequences, such as mediastinal sepsis and death (Kadish, 2006).

Definitive care is initiated after completion of the primary and secondary surveys. At this point the patient is transferred out of the emergency department either to theatre for surgical intervention or to the ICU for close monitoring and care.

The types of definitive care provided for patients who have suffered blunt or penetrating injuries to the abdomen or thorax are discussed below.

Several adult patients with blunt abdominal organ injury who are haemodynamically stable are successfully managed non-operatively (Van der Vlies et al., 2011). In children, most injuries to the abdominal organs are managed non-operatively with very high success rates (Zamakhshary and Wales, 2008; Gaines, 2009). These patients are admitted to the ICU for monitoring and therapy.

An adult or paediatric patient with blunt abdominal trauma who presents with shock due to intra-abdominal bleeding is immediately taken to theatre for surgical intervention in the form of an exploratory laparotomy. A laparotomy is also performed if a patient with penetrating trauma presents with multiple organ injuries, haemodynamic instability, prolonged hypoxia, significant intra-abdominal blood loss or evidence of hollow visceral injury (Adesanya et al., 2000; Thomson, 2003; Gaines, 2009). The vertical abdominal incision gives the surgeon sufficient exposure to the intra-abdominal organs to identify injuries, control bleeding and contain contamination. Where possible all dead and contaminated tissue is excised to leave healthy tissue behind (Vikram, 2011).

After surgery the patient is transferred to the ICU for further care and monitoring. Special attention is paid to the detection of the development of abdominal compartment syndrome (increased pressure in the abdomen). Abdominal compartment syndrome develops due to increased pressure in the intra-abdominal compartment from large-volume fluid resuscitation after major abdominal surgery and also tight abdominal wall closure after emergency laparotomy procedures. This increase in intraabdominal pressure leads to symptomatic organ dysfunction such as acute renal failure (Subramanian et al., 2008). Like adults, children can develop abdominal compartment syndrome, with a high associated mortality if not treated timely (Gaines, 2009).

The definitive management of blunt and penetrating chest injuries is very similar.

Pneumo- or haemothoraces are managed with the placement of an ICD, as mentioned previously, to release pressure from the pleural space, as part of standard care. Low-pressure, high-volume suction may be necessary to encourage re-expansion of collapsed lung regions (Paramasivan and Bodenham, 2007). Prompt drainage of blood from the pleural space is essential in adults and children with haemothoraces because as the haematoma organises, it may be replaced by fibrous scar tissue, causing lung entrapment, which predisposes the patient to chronic atelectasis, V/Q mismatch, pneumonia or empyema (Bliss and Silen, 2002). Drainage also provides a method to measure and monitor the volume and rate of blood loss. A thoracotomy may be indicated for direct closure of the wound if low-pressure, high-volume suction is unsuccessful (Keilin et al., 2003; Paramasivan and Bodenham, 2007).

Posttraumatic empyema may result from either blunt or penetrating chest injuries in 10–27% of adult cases and contributes to morbidity and mortality (Hoth et al., 2002; DuBose et al., 2012). A retained haemothorax is primarily associated with the development of posttraumatic empyema and is often caused by rib fractures. Blood trapped in the pleural space impairs its own absorption and forms an ideal environment for bacterial growth. The placement of an ICD may lead to contamination of a retained haemothorax and the development of empyema.

The diagnosis of posttraumatic empyema is made through chest CT and the presence of clinical findings such as increased leukocyte count, fever and worsening respiratory function.

The management of posttraumatic empyema includes thoracotomy for decortication and re-expansion of the involved lung, less invasive video-assisted thoracoscopy or intrapleural administration of fibrinolytic agents such as streptokinase or urokinase (Hoth et al., 2002; Paramasivan and Bodenham, 2007; DuBose et al., 2012).

These injuries may be managed conservatively initially with close patient monitoring. The unstable hypotensive patient is managed surgically with a median sternotomy incision or high antero-lateral thoracotomy incision to gain access to the great vessels, trachea or bronchi, oesophagus and the heart to repair damage. Repair of the thoracic aorta requires single lung ventilation and a thoracotomy incision at the fourth intercostal space on the left side of the chest wall (Keilin et al., 2003; O’Connor et al., 2009).

Entrance and exit wounds of gunshot injuries are debrided thoroughly. Necrotic tissue and debris create an ideal focus area for infection. Gas gangrene may develop in neglected wounds or those that have undergone inadequate debridement. Reconstructive surgery may be indicated for wounds with large loss of chest wall integrity (Clarke, 2003; De Groot and Van Oppell, 2003; Mauffrey, 2005).

Control of pain originating from the chest wall, accurate fluid management and aggressive bronchial hygiene are important components of the treatment of all patients with pulmonary contusion. Patients with severe pulmonary contusion should be monitored closely to ensure adequate oxygenation and organ perfusion. Intermittent positioning in prone can be used to optimise oxygenation (Cohn and DuBose, 2010).

The use of epidural analgesia has been shown to decrease the duration of mechanical ventilation (MV) and the rate of development of nosocomial pneumonia more so than the use of IV opioids in patients with multiple rib fractures and pulmonary contusion. Regional analgesia is also recommended for pain control in patients with rib fractures and pulmonary contusion (Cohn and DuBose, 2010). The survival rate of adults with pulmonary contusion and rib fractures is reported to change from 60–93.5% when pain is adequately controlled, allowing for early chest physiotherapy intervention and mobilisation (Cohn and DuBose, 2010).

Neutrophil-induced lung injury may be restricted with the early administration of hypertonic saline (Bastos et al., 2008; Cohn and DuBose, 2010), but large clinical trials are needed to confirm this finding. Restricted crystalloid IV fluids are given to prevent the development of pulmonary oedema. Intravenous red packed cells and plasma are given to restore blood volume. Diuretics may be used to treat pulmonary oedema (Bastos et al., 2008). Steroid use for patients with pulmonary contusion is not recommended as it may increase the risk for the development of pneumonia (Cohn and DuBose, 2010).

Between 20 and 35% of children with pulmonary contusion will require MV, fewer than in adults (Bliss and Silen, 2002; Norton et al., 2008). Ancillary measures in paediatrics include fluid restriction, supplemental oxygen, pulmonary toilet and pain control.

Diaphragmatic ruptures are managed through surgical intervention, with laparotomy incision being the golden standard. In some instances thoracotomy is performed for a right-sided hemi-diaphragm rupture (Chughtai et al., 2009; Vilallonga et al., 2011).

Unless rib fractures are causing instability, the main aim of management is pain reduction and prevention of pulmonary complications such as atelectasis and infection. This can be achieved by using the following methods.

Operative stabilisation of flail rib fractures can be performed if a patient continues to suffer with poor oxygenation despite optimal MV support (Fitzpatrick et al., 2010).

The severity of injury following blunt or penetrating trauma and increasing patient morbidity due to the development of infection or sepsis can lead to prolonged duration of MV, resulting in longer ICU stay. Under these circumstances the inter-professional team may consider replacing the patient’s endotracheal tube with a tracheostomy tube to make the process of weaning from MV easier for the patient. The care of the patient’s tracheostomy should be a priority for each member of the interdisciplinary ICU team, as poor standards of care directly influence the patient’s mortality (Mitchell et al., 2013).

On chest x-ray assessment the tracheostomy tube tip should extend more than half the distance between the stoma and the carina. The tracheostomy should be positioned parallel to the long axis of the trachea and should be two-thirds the diameter of the trachea in size (Kacmarek et al., 2013).

The tracheostomy tube should be securely fastened to the patient’s neck with tracheostomy tape. Tracheal injury and accidental decannulation (removal) can occur if the ventilator tubing pulls excessively on the tracheostomy tube. Good clinical practice involves reducing the leverage of the ventilator tubing on the tracheostomy by securing the tubing to drip stands above or next to the patient’s bedside.

Care of the patient with a tracheostomy can be enhanced by placing a clearly visible tracheostomy chart above the patient’s bed in the ICU or on the ward. Information that should be communicated through this chart includes the following: