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Key Points

  • Thoracic trauma is the second leading cause of traumatic death in the United States.

  • All patients require a rapid primary survey focused on patient airway, breathing, and circulation and stabilization of any emergent life–threatening conditions.

  • Emergent life threats in thoracic trauma include airway obstruction, tension pneumothorax, open pneumothorax, massive hemothorax, and pericardial tamponade.

  • In select penetrating trauma victims who suffer witnessed loss of vital signs, emergent thoracotomy can be a lifesaving procedure.


Thoracic trauma accounts for more than 16,000 deaths in the United States annually and constitutes approximately 25% of all trauma related mortality. For clinical purposes, patients can be divided into blunt and penetrating categories based on the mechanism of injury. Approximately 80% of cases of significant blunt thoracic trauma are secondary to motor vehicle collisions (MVC), whereas most cases of penetrating trauma in the United States are due to stab wounds and low–velocity handgun injuries.

Blunt Thoracic Injuries

Injuries that occur after blunt thoracic trauma include fractures (sternum/ribs), flail chest, pulmonary contusion, myocardial injury, and aortic injury. Although fractures to the sternum and ribs are usually not life–threatening, displaced and/or multiple rib fractures are an exception. Evaluate for injury to underlying structures—the mediastinum and great vessels with ribs 1–3, the lungs with ribs 4–8, and the liver or spleen with ribs 9–12. Flail chest occurs when ≥3 contiguous ribs are fractured in ≥2 places, thereby creating a “free floating” segment of the chest wall.

Pulmonary contusions are focal regions of bruised lung parenchyma resulting in alveolar hemorrhage and edema, which can significantly impair normal respiratory function. They typically develop over several hours post injury and are often missed on the initial patient assessment.

Blunt myocardial injury (BMI) should be considered in any patient with significant direct trauma to the anterior chest wall. Myocardial contusions present as regions of “stunned” tissue that clinically behave analogous to myocardial infarctions. Rarely, patients with significant BMI may progress to outright cardiogenic shock due to impaired pump function or dysrhythmia.

Blunt aortic injury (BAI) is seen in patients when a rapid decelerating force causes significant sheer strain and secondary rupture of the aorta. More than 80% of cases occur at the site of the ligamentum arteriosum just distal to the takeoff of the left subclavian artery. Roughly 20% of patients with BAI will survive to emergency department (ED) presentation because of the tamponading effects of an intact adventitia. As the presenting symptoms and clinical picture are highly variable, a high index of suspicion for BAI should be maintained for any patient with the appropriate mechanism of injury.

Penetrating Thoracic Injuries

Injuries common after penetrating thoracic trauma include pneumothorax, hemothorax, cardiac injury, pericardial tamponade, great vessel injury, and tracheobronchial injury. Pneumothoraces (PTX) are rather common after penetrating thoracic trauma, but ...

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