Chapter 25

Injuries to the chest are common after both blunt and penetrating trauma. Blunt thoracic injuries are responsible for approximately 8% of all trauma admissions in the United States, with motor vehicle crashes being the most common mechanism.1,2 In one recent report from the Los Angeles County Hospital, penetrating chest trauma accounted for 7% of all trauma admissions and 16% of all penetrating trauma admissions overall.3 A 1961 study described a 28% mortality with blunt chest injuries as compared to a 7% mortality following penetrating injury.4 Associated injures were common and were associated with a 42% mortality. These figures have not changed, as a more recent study described approximately a 25% fatality rate as a direct result of thoracic injury with chest trauma playing a contributing role in 50% of nonpenetrating injuries overall.5

Despite the prevalence of thoracic injury following trauma, the majority of patients can be managed nonoperatively. Between 18% and 40% of patients sustaining thoracic trauma can be treated with tube thoracostomy alone. A thoracotomy will be required for between 3% and 9% of patients. Even among those with penetrating trauma, only 14% of stab wounds and between 15% and 20% of gunshot wounds to the chest require thoracotomy.3

Operative mortality varies between 5% and 45%, with approximately 30% of patients requiring lung resection at the time of thoracotomy.4,5 This wide variability is almost certainly related to differences in mechanism of injury, inclusion of cardiac and major thoracic injury in some of the datasets, the extent of pulmonary resection needed, and concomitant extrathoracic injuries.413 The influence of thoracic trauma on mortality is particularly striking among patients who die within 1 hour of arriving to a trauma center. In those patients, thoracic trauma, especially thoracic vascular injury, is second only to central nervous system injury as the most common cause of death after hospital admission.

The determination of the optimal treatment for patients with thoracic injuries remains a challenge. Technological advances, particularly the evolution of sophisticated imaging, have allowed clinicians to make the diagnosis of major thoracic injury more quickly. Advances in critical care have made postoperative management more sophisticated. Improved approaches for nonoperative management may make the need for operative exploration even less frequent. Despite these advances, however, a modest number of patients still require thoracotomy. Thus, clinicians caring for injury must adequately appreciate the indications for operation and understand the treatment options in the emergency department as well as in the operating room. Thoughtful decision making based on a comprehensive appreciation of the anatomic relationships of the thoracic cavity and the physiologic principles that govern trauma is necessary to insure the highest survival and optimize functional recovery.

The lungs sit in each hemithorax. While physiologically quite complicated, in fact, the lungs are anatomically simple, consisting of primarily alveoli and blood vessels. The lungs have a dual blood supply, with a ...

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