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Introduction

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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.

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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.

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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.

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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 ...

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