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Chest trauma was documented in the Edwin Smith Surgical Papyrus, written by Imhotep over 5000 years ago.1 The first recorded operation in the United States was removal of an arrowhead from an Indian’s chest by Cabeza de Vaca in 1635.2 The mortality from chest injury during war has ranged from 28.5% during the Crimean War (1853–1856) to a less than 5% today. Currently, in the United States more than 16,000 deaths occur annually as a direct result of thoracic trauma.3


The chest composes almost one fourth of the total body mass and is therefore often subjected to injury during trauma from any etiology. Regardless of etiology, a patient with thoracic trauma requires logical and sequential evaluation of the chest injury, followed by focused therapy, which, in some instances (less than 20% of the time), involves an operation. Those evaluating and treating must understand the anatomy, physiology, and function of each of the thoracic organs, as well as how each decision and treatment will affect outcome. The acute care surgeon must understand thoracic organ responses to and manifestations of various injuries, appropriate evaluation tools, which evaluations might be misleading, redundant, or unnecessary, and approaches to therapy. It is essential to be able to recognize when minor intervention or damage control should be applied to a chest injury condition verses when a formal surgical intervention is indicated. When surgery is performed the surgeon must also understand benefits and limitations of the various patient positions and incisions. Finally, as every evaluation and therapy has its potential hazard or contraindication, the acute care surgeon must understand traditional concepts that are either dated or currently considered controversial.


Injury to the chest and its organs may be caused by penetration (from missiles, fragments, knives, needles, and other objects), blunt forces, iatrogenic misadventure, blasts, ingestion of toxic substances, and, indirectly, from abnormal medical conditions elsewhere in the body. Each of these etiologies has differing initial manifestations as well as evaluation and treatment approaches.46 These differences are more specifically discussed elsewhere in this textbook. This overview chapter contains many cultural views, which have become doctrine and standard use by the authors, but, admittedly, based on Class 3 evidence, which might differ from the culture in other trauma centers.


The thoracic cavity is surrounded by a flexible boney cage, supported by respiratory and locomotive muscles. Three separate compartments house the two lungs with their five segments that are attached by vascular structures to the central cardiovascular compartment. In addition, the trachea and bronchus connect the lungs to the pharynx, and a series of nerves traverse the thoracic cavity. In the healthy patient, the lungs and heart are separated from their surrounding cavities by a smooth fibrous pleural lining. Following inflammation, fusion of these linings may alter some physiology and, consequently, some treatment options. Prior to any procedure following thoracic trauma, the surgeon is well advised to review the regional anatomy, determine ...

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