Thoracic injuries can involve the chest wall, lungs, heart, great vessels, trachea, esophagus, and diaphragm. Penetrating injuries require swift identification and treatment of life-threatening conditions like hypoxia and hemorrhage. Initial assessment involves primary and secondary surveys, along with chest x-rays, CT scans, and other imaging to diagnose injuries. Management depends on factors like the size and location of wounds. Large defects or injuries to organs may require emergency thoracotomy or thoracoscopy, while smaller wounds can sometimes be treated without surgery. Proper diagnosis and treatment can significantly reduce late complications from thoracic trauma.

1. A R D I A N S Y A H
Cardiothoracic and Vascular Surgery Trainee
University of Indonesia

2. Thoracic trauma typically affects the young
Lifethreatening injuries need to be identified and treated Immediately
Hypoxia, hypoventilation, and hemorrhage are the primary killers
Mechanism of injury is important
Severity : Velocity, biomechanics, characterirtics of the weapon
Further investigations : computed tomography (CT), angiography,
esophagoscopy, esophagography, and bronchoscopy
Thoracic injury may occur in the chest wall, lungs and pleura, trachea,
bronchus, heart, thoracic great vessels, esophagus, and diaphragm
Appropriate early diagnosis and management of rapidly fatal and potentially
fatal penetrating thoracic injuries is paramount and also significantly decreases
late complications
Physical examination is the primary tool for diagnosis
Penetrating thoracic injuries also occur during diagnostic and therapeutic
procedures
Anteroposterior chest radiograph remains the standard initial evaluation
Kozower BD, Patterson GA. Pearson’s thoracic and esophageal surgery. Patterson GA, Cooper JD, Deslauriers J. Et al. Philadelphia: Elsevier; 2008

3. Chest wall injury accounts for 10% off all penetrating chest trauma
Creates a communication between the external environment and pleural space
• Fracture of a rib, tearing the pleura and underlying lung, pneumothorax and hemothorax
Management : PRIMARY SURVEY followed by SECONDARY SURVEY
Chest radiography is mandatory after a primary survey.
• Focused assessment with sonography for trauma (FAST) examination can detect smaller hemothoraces
Sucking wound :
• Size of the chest wall injury reaches two thirds the size of the tracheal diameter, must be treated rapidly, closure of
large, open chest wall defects can be a formidable task
• The treatment: application of a sterile cover and entirely taped securely on three sides
Vascular lesions
• Found and account for 90% of hemothorax due to injury to intercostal vessels and internal mammary vessels.
• The presence of a fractured sternum and an abnormal mediastinal contour prompts a search for injury to the great
vessels
Hematothoraks :
• Placement of a large (32, 36 Fr) chest tube.
• Closed drainage alone (500-1500 mL) that stops bleeding after thoracostomy
• Greater than 1500 to 2000 mL and continued bleeding of more than 100 to 200 mL/hr are indications for emergency
thoracotomy or thoracoscopy.
• Small clots will probably be resorbed and do not require operative removal. Massive clots : evacuated surgically.
Kozower BD, Patterson GA. Pearson’s thoracic and esophageal surgery. Patterson GA, Cooper JD, Deslauriers J. Et al. Philadelphia: Elsevier; 2008

4. Can be life threatening if mismanaged  managed quickly and
thoroughly
Penetrating injury of Laryngotrachea : extend deep to the platysm
Injuries to the main bronchi and intrathoracic trachea are more
prevalent than those to the cervical trachea
Usually causes respiratory distress and inability to ventilate
adequately
Management : PRIMARY SURVEY followed by SECONDARY
SURVEY and Imaging findings
THE FALLEN-LUNG sign
• refers to the unusual appearance of a collapsed lung or lobe in the setting
of bronchial injury and is thought to be due to disruption of the normal hilar
attachments of the lung, causing the collapsed lung to droop peripherally
rather than centrally
THE FALLEN-LUNG
Kozower BD, Patterson GA. Pearson’s thoracic and esophageal surgery. Patterson GA, Cooper JD, Deslauriers J. Et al. Philadelphia: Elsevier; 2008

5. laryngoscopy and bronchoscopy are performed. Esophagoscopy also (50% of patients with an airway
injury also have a digestive tract injury)
small injuries without appreciable leaks who do not require positive-pressure ventilation can be
treated nonoperatively
The most crucial aspect of tracheal injury is the management of the airway, tracheostomy if
needed
In the totally separated trachea : , the distal end may retract into the mediastinum, best found by
inserting a fi nger , bring it to the surface of the wou and insert ETT. in a partially disrupted trachea,
tube inserted through the damaged area is the best
Anterolateral and posterolateral thoracotomies are the most used operative approache. using a double-
lumen tube and selective bronchial intubation, requires an interrupted absorbable monofi lament suture
Kozower BD, Patterson GA. Pearson’s thoracic and esophageal surgery. Patterson GA, Cooper JD, Deslauriers J. Et al. Philadelphia: Elsevier; 2008

6. May extend from the surface of the lung toward the hilum or follow the
trajectory of the penetrating object
Lung laceration :
• pneumothorax  tension pneumothorax  Life threatening.
• Needle Thoracosintesis followed by thoracostomy with underwater-seal drainage
Lung laceration : hemothoraces.
• Most hemothoraces from injury to lung parenchyma stop bleeding without intervention.
• Massive hemothorax  THORACOTOMY EMERGENCY. more than 1500 mL of blood in
the pleural space. 200 to 250 mL of blood per hour
The operative management :
• Oversewing of small lung lacerations (pneumonorrhaphy),
• Wedge resection
• Anatomic resection
Kozower BD, Patterson GA. Pearson’s thoracic and esophageal surgery. Patterson GA, Cooper JD, Deslauriers J. Et al. Philadelphia: Elsevier; 2008

7. Leading cause of traumatic death in urban areas
• Only 25% of patients with heart wounds survive to reach the hospital
Small wounds of the heart, caused by ice picks, knives, or other small agents
• because of the development of cardiac tamponade, reach the hospital alive.
Extensive lacerations or large caliber gunshot wounds
• die almost immediately as a result of rapid and voluminous blood loss
Diagnosis : TRIAD BECK (Muffl ed heart tones, hypotension , neck veins are distended)
Imaging
• Chest radiograph may demonstrate a widening of the cardiac silhouette
• Ultrasonography or Echocardiography shows presence of blood in the pericardial space
Pericardiocentesis can be both diagnostic and therapeutic
Cardiac lesions may be initially inapparent
• Wounds of the ventricle may be self-sealing, and small lacerations may be contained by clot within the pericardium,
• Ventricular injuries are more common than atrial injuries, and the right side is involved more often than the left side
Left anterolateral thoracotomy is the preferred initial approach
• Distal coronary injuries are usually ligated, whereas proximal injuries may require bypass grafts
• Intracardiac shunts or valvular injuries in patients who survive are usually minor and do not require emergent repair
Kozower BD, Patterson GA. Pearson’s thoracic and esophageal surgery. Patterson GA, Cooper JD, Deslauriers J. Et al. Philadelphia: Elsevier; 2008

8. More than 90% of thoracic great
vessel injuries are caused by
penetrating trauma
Thoracic great vessel injuries are
almost always nonexistent in
patients arriving alive at
emergency departments
Location : Aorta, Pulmonary
Artery, Vena Cava, innominate
artery, carotid, subclavian,
intercostals, and internal thoracic
vessels
Imaging : chest radiograph, CT,
USG/Echo. CT Angiography
The initial approach includes
pericardiocentesis and chest tube
insertion
Surgical Approach : Median
sternotomy,, Left anterolateral
thoracotomy, posterolateral
thoracotomy
The principles of vascular trauma are to not
approach the bleeding directly but rather to
obtain proximal and distal control
Kozower BD, Patterson GA. Pearson’s thoracic and esophageal surgery. Patterson GA, Cooper JD, Deslauriers J. Et al. Philadelphia: Elsevier; 2008

9. Esophagus
The prevalence of injury to the esophagus due to
external trauma is less than 1% of patients,
Recognizing injury is difficult
Prompt investigation including radiography and
endoscopy has high diagnostic sensitivity
The principles in the management of major
esophageal injuries are those of early operation,
primary repair with adequate tissue buttressing and
two-layer surgical closure when possible, and wide
mediastinal drainage
Complications after esophageal repair include
esophageal leaks and fi stulas, wound infections,
lethal mediastinitis, empyema, sepsis, and
pneumonia
Diaphragma
Diaphragmatic injury is suspected in any penetrating
thoracic wound at or below the fourth intercostal
space anteriorly, sixth intercostal space laterally, or
eighth intercostal space posteriorly
Penetrating diaphragmatic injuries are frequently diffi
cult to diagnose
The diagnosis is suspected or confirmed by chest
radiography, Ultrasonography, CT, and magnetic
resonance imaging will confi rm the diagnosis.
Diagnostic peritoneal lavage appears to be the best
procedure
laparoscopy and laparotomy are the unique
diagnostic tools
Kozower BD, Patterson GA. Pearson’s thoracic and esophageal surgery. Patterson GA, Cooper JD, Deslauriers J. Et al. Philadelphia: Elsevier; 2008

10. Timing
Immediate
Early
Late
Kozower BD, Patterson GA. Pearson’s thoracic and esophageal surgery. Patterson GA, Cooper JD, Deslauriers J. Et al. Philadelphia: Elsevier; 2008

11. Indications
Tamponade
Exsanguinating
intrathoracic
hemorrhage,
massive
Hemoptysis
massive
Massive air leak
Cardiac arrest
Intra-abdominal
hemorrhage
requiring aortic
cross clamping
Immediate Operation
Kozower BD, Patterson GA. Pearson’s thoracic and esophageal surgery. Patterson GA, Cooper JD, Deslauriers J. Et al. Philadelphia: Elsevier; 2008

12. Hernia of the chest wall
Missed tracheobronchial laceration may result in significant strictures
Delayed tracheoesophageal fistula
Residual hemothorax
Embolization to the pulmonary arteries
cardiovascular arteriovenous fistulas
Chylothorax and Injury of the phrenic nerve
Kozower BD, Patterson GA. Pearson’s thoracic and esophageal surgery. Patterson GA, Cooper JD, Deslauriers J. Et al. Philadelphia: Elsevier; 2008