Thoracic Trauma

Thoracic injury directly accounts for 20 to 25% of deaths from trauma, resulting in more than 16,000 deaths annually in the United States. The most common cause of injuries leading to accidental death in the United States is motor vehicle collisions (MVCs) in which immediate deaths are often caused by rupture of the myocardial wall or the thoracic aorta. Early deaths (within the first 30 minutes to 3 hours) resulting from thoracic trauma are often preventable. Causes of these include tension pneumothorax, cardiac tamponade, airway obstruction, and uncontrolled hemorrhage. Because these problems are often reversible or may be temporized nonoperatively, it is vital that emergency physicians be thoroughly familiar with their pathophysiology, clinical presentation, diagnosis, and treatment. Approximately 75% of patients with thoracic trauma can be managed expectantly with simple tube thoracostomy and volume resuscitation. Therefore initial care and disposition of these patients is usually performed by emergency physicians. Definitive care of these patients is often multidisciplinary in nature, involving trauma surgeons, cardiothoracic surgeons, and intensivists. Improvement in the understanding of the underlying physiologic mechanisms involved, the advancement of newer imaging modalities, minimally invasive approaches, and pharmacologic therapy contribute to decreasing the morbidity and mortality of these injured patients. The role of multidetector helical computed tomography (CT) scanning in the evaluation of trauma patients continues to expand. Although CT scans provide much greater diagnostic sensitivity than plain radiography, the precise indications for CT scanning in trauma patients remain unclear. Concerns regarding cost, contrast-induced nephrotoxicity, and cumulative radiation exposure to the thorax have been mounting. Injuries to the lung parenchyma are common in severely injured patients and include contusion, laceration, and hematoma. Hemothorax and pneumothorax are also common injuries in patients with thoracic trauma. Treatment of these injuries has changed during the past decade primarily because of advances in diagnostic imaging techniques and an increased understanding of the pathophysiology.