Trauma is the leading cause of death in individuals between the ages of 1 and 44. In the Western world, motor vehicle accidents account for the majority of these deaths. In a post 9/11 world, it is difficult to argue that practicing thoracic surgeons should not attain a core level of competency in advanced trauma life support techniques. Traumatic injuries are categorized as blunt, penetrating, or caustic. Surgical techniques for blunt and penetrating esophageal trauma are described in Chapters 48 and 49. Corrosive esophageal injury is discussed in Chapter 50. This chapter concerns the management of blunt and penetrating chest injury in an emergent setting, whether in the field, at a disaster relief facility, a community hospital, or other rural setting, where the thoracic surgeon may be called upon to help manage an acute patient with traumatic thoracic injuries.

Morbidity and mortality from thoracic injuries may be categorized as immediate, within minutes to hours, and late. Pattern recognition and aggressive early treatment are crucial to saving lives, and early proactive interventions can significantly improve immediate and late outcomes. Many of these interventions are considered routine in modern thoracic surgery practice, but require a high level of training and equipment. This chapter reviews the pathophysiology of traumatic thoracic injury and presents some urgent and emergent procedures that can be performed by providers with a basic level of thoracic surgery training and associated competencies working in a limited resource setting.

The principles and procedures described in this chapter follow the Advanced Trauma Life Support (ATLS) Program.¹ Over the past decades, the delivery of trauma care in the United States has greatly benefited by the development of this program, as well as by the development of a system for accrediting regional level I trauma centers. A level 1 facility must meet certain objective parameters of service, expertise, and availability of resources. Unfortunately, the majority of hospitals in the United States remain unaccredited for trauma care or are designated at the lowest level (III). Nevertheless, the need to care for trauma victims at less than a level I setting persists.

Most general thoracic surgical procedures are associated with a higher morbidity and mortality compared with non-thoracic surgical procedures. In the United States, the expected mortality from multiple rib fractures is 3% to 5% in an elderly patient, compared with the estimated mortality for lobectomy of 1% to 5%. Pneumonectomy and esophagectomy have estimated mortalities of 4% to 20% and 2% to 20%, respectively, and all of these values are experience-dependent (i.e., whether the treatment is performed at a high- vs. low-volume center). Hence, successful complex general thoracic procedures should be performed by an experienced team, with expertise in perioperative management, in a well-equipped and well-staffed operating facility. These include, but are not limited to, a surgeon with general thoracic experience; an anesthesia team familiar with one-lung ventilation and epidural anesthesia for pain control; blood bank capabilities; chest imaging; continuous pulse oximetry; oxygen supplementation; intensive as well as intermediate care units; dedicated nursing and physical therapy, as well as respiratory therapy.

The fundamentals of attaining good patient outcomes include accuracy of diagnosis, volume restriction before, during, and after the surgical procedure, excellent pain control, and early ambulation. Volume restriction is critical to preventing right heart failure for which there is no effective treatment. Pain control in the perioperative period is critical to encouraging cough, which aids clearance of secretions to prevent atelectasis and pneumonia, both major causes of postoperative morbidity and mortality.

Therefore, when working in the field or a community hospital with an inexperienced team, poor support systems, and limited resources, major thoracic procedures should only be performed when no other therapeutic option is available. The goal of this chapter is to advise the surgeon with minimal or no thoracic trauma training to recognize “patterns” and identify “simple” procedures that can be used to convert urgent life-threatening situations into salvageable and stable conditions.

The thoracic cavity extends from the thoracic inlet to the diaphragm. The cavity is comprised of 12 ribs anchored to the thoracic vertebra posteriorly and the sternum and costochondral angle anteriorly. This mobile bony cage protects vital structures including the heart, lungs, esophagus, and great vessels. The first seven ribs attach directly to the sternum. The first rib is flat and strong: it requires great force to fracture. The 11th and 12th ribs are floating ribs. Rib fractures in adults can be associated with additional intrathoracic injuries such as lung contusion even when the pleural covering is intact. The ribs of small children are more elastic than adults and thus moderate and sometimes severe injuries occur without fracture. Age, therefore, plays an important role in recognizing patterns that point to associated injuries.

During inspiration the diaphragm contracts moving downward; as the rib cage expands, the sternum is pushed anteriorly and the lung volumes increase. During expiration the diaphragm relaxes as it moves up the rib cage and the lung volumes decrease. A healthy adult breathes approximately 12 times a minute, which amounts to about 17,280 breaths a day. The respiratory rate typically increases with injury. Thus, a disturbance of the respiratory mechanics by trauma, iatrogenic injury, or other reason is a major source of thoracic morbidity and mortality. This is fully addressed in the sections on rib fractures and postoperative pain management below.

The trachea enters the thoracic inlet anterior to the esophagus. In a normal adult, it is approximately 12 cm in length. The carina lies directly behind the angle of Louis. The proximal third can be easily accessed from the neck, the distal third is best accessed from the right chest, while the middle third is difficult to reach and is best accessed with sternotomy. The left mainstem bronchus is 4 cm long and has an acute angle from the carina; it lies between the aortic arch and the pulmonary artery.

During surgery, the anesthesiologist prepares the patient for one-lung ventilation with collapse of the operative lung. This is critical to facilitating a workspace during chest surgery. Additionally, while the lung is collapsed, the blood flows preferentially to the opposite lung, thereby increasing the overall oxygenation of blood during surgery. This physiologic shunting is also important for decreasing the blood loss during surgical procedures on the unventilated lung.

Any injury to the central mediastinal area, often referred to as the “box” (Fig. 47-1), should trigger a low threshold for surgical exploration. It is prudent to remember that young healthy adults have great cardiopulmonary reserve. In the setting of serious trauma, the young adult often may appear to be remarkably “stable,” their body compensating for the injury, only to suddenly collapse and rapidly die.

Ultrasound, chest x-ray, fluoroscopy, and chest computed tomography (CT) may be the only imaging modalities available.

Plain Chest Films

The chest x-ray has been used since 1895 to diagnose diseases of the chest (Fig. 47-2). It is useful for assessing the lungs, heart, chest wall, diaphragm, major vessels, and spinal column as well as soft tissue. The lungs can be assessed for nodules or masses, cavitary lesions, and pleural and pericardial effusions. Additionally, it enables assessment of the great vessels, mediastinal structures, and chest wall. Typically, two types of exams exist:

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  The PA and lateral exam consists of two x-rays; the PA or posteroanterior view, where the patient faces the x-ray film, and the lateral view where the patient is turned sideways. Having two views enables more precise recognition and localization of abnormalities. When only a PA view is available, consideration of anatomic landmarks, such as fissures and selective obscuration of anatomic structures, may be adequate for localizing pathology.

  
  
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  The pleural cavity is examined for pneumo- or hemothorax, with attention to deepening or blunting of the costophrenic angles. The heart and pericardium are assessed for contour; a large contour may be a sign of hemopericardium. Next, the position of the diaphragm is evaluated and the abdominal cavity is examined for free intraperitoneal air and the aeration of the abdominal contents. The bony structures are examined for fracture. The mediastinum is assessed for size as are the great vessel notches and air (Table 47-1).

Ultrasonography

Ultrasound has limited utility in the chest because ultrasonic waves are interrupted by air in the lung. The amplification of ultrasound passing through fluid, however, can provide superior visualization of pleural effusions as well as physiologic information regarding diaphragmatic and cardiac function. In trauma, a study is performed called focused assessment with sonography for trauma (FAST). It is used to assess the abdominal cavity and the pericardium for the presence of blood. The pericardial window is the most sensitive window for blood around the heart. Furthermore, a skilled examiner can also find air or blood in the costophrenic angle as mentioned above.

Fluoroscopy

Fluoroscopy is useful for assessing the esophagus, great vessels, and the diaphragm. Fluoroscopy is a dynamic examination and therefore provides information about the function of the organs examined.

Computed Tomography

CT is the standard examination for chest pathologies today. If available, a chest CT (especially with 3D reconstruction) in a stable patient can accurately diagnose and determine the extent of a traumatic chest injury and is useful for surgical planning.

Management of Thoracic Trauma

When assessing treatment options, triage is critical. The decision to treat or transfer a patient should be based on the provider’s level of experience, resources available, and the availability and accessibility to more specialized care. When possible, the immediate emphasis should be on “damage control” as opposed to definitive care. Whenever possible, damage control can and should be expediently performed for life-threatening injuries (e.g., tension pneumothorax) that can be safely and successfully converted to a stable non-life-threatening condition. For other conditions, it may be best to stabilize locally and then transfer the patient to a level I trauma center where he/she can receive a higher level of care.

Thoracic trauma is a significant cause of immediate and delayed patient mortality. There are two major types of thoracic trauma: blunt and penetrating trauma. In contrast to other diseases encountered by a general surgeon, reaction time and pattern recognition are critical for obtaining optimal outcomes.

Basic life-threatening injuries that should be recognized and converted to stable conditions are: (1) loss or obstruction of airway, (2) pneumothorax (tension, hemo, simple), and (3) pericardial tamponade. More advanced situations may include severe intrathoracic hemorrhage (caused by bleeding from the chest wall, cardiac or pulmonary lacerations, or injury to the great vessels). Some injuries like those to the great vessels, especially in the setting of limited resources, might be unsalvageable; whereas a simple laceration of the right ventricle may be easily repaired. Thus, in a minimal resource setting, triage should account for surgical expertise, facilities, equipment, and support needed to salvage the patient. Few patients with thoracic trauma will require a thoracotomy (<10% for blunt injuries, 15%–30% for penetrating injuries). In general, blunt trauma causes more extensive injuries that are harder to repair, while penetrating trauma (especially a stab wound) is easier to repair.

Chest trauma typically leads to lung injury (i.e., contusion, consolidation, and atelectasis) and disruption of chest wall mechanics (i.e., rib fractures, diaphragmatic injuries, muscle contusions, and pain). Over time, this can lead to a vicious cycle of hypoxia, hypercarbia, and acidosis. The majority of patients who suffer from thoracic trauma and reach a medical care facility alive can be managed with small lifesaving interventions. Examples include: (1) surgical airway, (2) tube thoracostomy, and (3) pericardial window. These simple interventions are easy to master and can convert an unstable patient with a life-threatening injury to a stable patient. The late sequelae of chest trauma, particularly rib fracture, lung contusion, and pneumonia, are associated with late preventable deaths in many trauma victims.

The management of thoracic trauma focuses on the principles taught by the ATLS Program for Doctors.¹ The ABC (airway–breathing–circulation) priority is universally important: establishing and maintaining a patent airway, ensuring breathing (i.e., relief of pneumothorax, tension pneumothorax, hemothorax) with external ventilatory support as needed, and aiding circulation (i.e., hemorrhage control, volume resuscitation, relief of tamponade, etc.). Hypoxia is the most serious result of chest injury. It can be due to loss of airway or altered breathing and must be treated immediately. Patients with chest trauma should be examined according to ATLS guidelines:

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   Primary survey

   
   
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   Resuscitation and vitals

   
   
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   Secondary survey

   
   
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   Definitive care

Blunt trauma frequently occurs as a result of motor vehicle accidents and falls. The mechanism of injury and time elapsed will shed light on the severity of the injury as well as the organs likely affected. On examination, the patient’s vital signs (pulse, blood pressure, and respiratory rate) and mental status will give an indication of the severity of injury. On physical examination, the trachea should be central in the neck. If the trachea is deviated, pneumothorax should be suspected. The rib cage is examined by pressing along the ribs bilaterally. If a step, instability, or tenderness is found, fractures are suspected. Subcutaneous emphysema, rib fractures, or hemodynamic instability suggest significant injury to the lung (e.g., contusion), possible pneumothorax, and possible significant hemothorax. The lungs as well as heart are auscultated. If the respiratory sounds are distant or nonexistent in one hemithorax or region, a pneumothorax or hemothorax should be suspected. If the patient has distant heart sounds, a narrow pulse pressure, and distended neck veins, a cardiac tamponade should be suspected. It is important to remember that anoxia (and shock) will lead to anxiety, combative behavior, and confusion, which must be managed appropriately by treating the underlying cause and by administering supplemental oxygen, thereby improving oxygenation. Additionally, it is important to remember that patients can exsanguinate into the chest cavity. For all injuries that occur in the field, the question of need for antibiotic coverage should be addressed, as well as tetanus vaccination status and need for vaccination.

Airway

A secure airway must be established swiftly to prevent brain damage from hypoxia (Fig. 47-3).

Foreign-Body Removal

Ingestion of a foreign body is a common life-threatening condition. When a foreign body is lodged within the trachea or bronchial tree proximal to the carina, the patient presents with labored breathing associated with dyspnea and/or fixed wheezing (on inspiration and expiration). This most typically is found in the toddler population as a result of foreign-body aspiration. When the occlusion is complete, it can result in rapid demise leading to respiratory arrest. The initial treatment is to dislodge the object by delivering a succession of forceful blows to the back (i.e., palm slaps between the scapulae) or a Heimlich maneuver (i.e., physician stands behind the patient with fist pressed deeply on epigastrium to induce a rapid increase in intrathoracic pressure which causes the foreign body to dislodge so that it can be coughed up by the patient).

Rigid Bronchoscopy

If these maneuvers fail and the provider is experienced in rigid bronchoscopy, an attempt can be made to remove the object bronchoscopically. Position the patient with his/her head at the edge of the bed, and then anesthetize intravenously with an anesthetic agent such as ketamine. Insert the rigid bronchoscope (a straight hollow tube with light source) perpendicular to the mouth and tongue elevating the epiglottis. Then perform a full extension of the head and cannulation of the trachea. Advance the scope gently into the trachea; the foreign body can be removed piecemeal using a grasper or it can be pushed into the scope and then removed with the scope. If neither is possible, and complete obstruction occurs, the foreign body can be pushed distally into a mainstem bronchus to enable ventilation of one lung, thereby stabilizing the patient.

During rigid bronchoscopy, care must be taken not to break any teeth. Adequate relaxation is crucial. This is a technically demanding procedure that should be performed only by those with proper training or when no other solution exists for reestablishing an airway. In the stable patient, soft tissue x-rays of the neck may aid in viewing a foreign body in the airway.

Caution: When a foreign body causes incomplete occlusion of the trachea and cannot be dislodged by simple noninvasive means and the surgeon is inexperienced in rigid bronchoscopy or does not have the necessary instruments or materials, it may be easier and safer to perform tracheostomy and then apply suction to remove the object through the stoma as described below.

Jet Ventilation

If attempts to remove a foreign body or establish a secure airway are unsuccessful, jet ventilation can be used as a temporary treatment until a secure airway is established. A needle or IV catheter is placed through the cricothyroid membrane and high flow oxygen is administered.

Direct Tracheal Cannulation

Cricothyroidotomy Cricothyroidotomy is performed by opening an urgent surgical airway through the cricothyroid cartilage. This is the quickest, safest, and least technically demanding procedure for relieving a proximal airway obstruction and reestablishing a surgical airway. The cricothyroid cartilage lies anteriorly between the larynx and the first tracheal ring. It is easy to palpate. Pressure in this region causes discomfort. This is the most cranial portion of the trachea. It is also the narrowest portion of the trachea. Cricothyroidotomy should not be performed in children younger than the age of 8 years unless no other option is available, because the first tracheal ring is a complete cartilage ring. Cricothyroidotomy above this level can lead to long-term disability secondary to stricture. Prior to procedure, if possible, the patient should be preoxygenated using a bag mask with jaw maneuver and concentrated oxygen if available.

Equipment needed: #11 blade, endotracheal or tracheotomy tube. Pulse oximetry is suggested. If oximetry is not available, the surgeon must remember that central cyanosis (seen with lip discoloration) correlates with a saturation level <85% in whites but may not be detected until SO₂ drops below 75% in patients with dark skin. Ambo-bag and suction.

Positioning: If the cervical spine has been cleared of injury, a shoulder roll (or 1 L IV fluid bag) is placed horizontally between the scapulae, the patient is positioned supine, and the neck is fully extended. If the cervical spine has not been cleared, the procedure is performed with in-line stabilization.

Procedure: The region of the cricothyroid membrane is avascular. Typically, there is little between the skin and the membrane. A 1 cm vertical midline incision is made in the skin and carried down to the trachea. The cricothyroid membrane is identified and incised horizontally, the stoma is dilated, and the cricothyroidotomy cannula is inserted through the stoma. The cannula is then fixed to the skin using multiple sutures. This procedure has been performed in field situations with improvised means such as using a jack-knife to make the hole and then inserting a car key horizontally and then vertically to stent open the trachea, or using a pen to stab into the cricothyroid ring and then removing the ink carrying cartridge to establish the airway.

Tracheostomy A tracheostomy is a stoma or opening of the trachea that enables direct ventilation, by bypassing the oropharynx, larynx, and proximal trachea. It is the classical approach for acute access to a proximally obstructed airway, or chronic access for long-term ventilatory support, pulmonary toilet, or bypass of a proximal tumor or stricture. A tracheostomy can be performed on individuals of all ages. In the event of prior surgery for a head and neck tumor, where a proximal surgical resection is performed and the proximal trachea is resected, a tracheostoma can be performed in the lower neck or chest. This may require tracheal release maneuvers and is beyond the scope of this chapter. Pitfalls of tracheostomy include loss of airway, injury to posterior membranous wall and or esophagus, tracheo-innominate fistula.

The procedure can be performed at the bedside or in an operating room.