Chapter 25: Lung, Trachea, and Esophagus

INTRODUCTION

Injuries to the chest are common following 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.^1,2,3 In one report, penetrating chest trauma accounted for 7% of all trauma admissions and 16% of penetrating trauma admissions overall.⁴

Despite the prevalence of thoracic injury following trauma, the majority of patients can be successfully managed nonoperatively. Between 18% and 40% of patients sustaining thoracic trauma can be treated with tube thoracostomy alone, and thoracotomy will be required for between 3% and 9% of patients. Even among those with penetrating chest trauma, only 14% of stab wounds and between 15% and 20% of gunshot wounds require thoracotomy.⁴

Operative mortality varies between 5% and 45%; approximately 30% of patients undergoing thoracotomy requiring a pulmonary resection.³ This wide variability is related to differences in mechanism of injury, inclusion of cardiac and major thoracic vascular injury in some of the datasets, the extent of pulmonary resection performed, and concomitant extrathoracic injuries.^3,5,6,7

Technological and imaging advances, particularly the expanded role of CT scanning, have allowed clinicians to characterize thoracic injury rapidly and accurately. Some injuries are minor, such as small pneumothoraces, which require no treatment. However, major injuries require rapid and definitive care. In an era of nonoperative management for many injuries, clinicians caring for trauma patients must appreciate the indications for operation and understand the treatment options in the emergency department as well as in the operating room. Sophisticated judgment is essential when evaluating the patient with multiple and often competing injuries.

INJURY TO THE LUNGS

While physiologically complicated, the lungs are anatomically simple, consisting primarily of alveoli and blood vessels. The paired large pulmonary artery and vein are high volume, low pressure circuits. The bronchial vascular bed is characterized by a higher systemic pressure but relatively small caliber vessels. Injury to the protective bony thorax serves as a marker for pulmonary injury following blunt trauma in adults. In contrast, the greater chest wall elasticity in children may result in significant pulmonary injury without associated thoracic wall injury.

The anatomic simplicity of the lungs suggests a limited parenchymal response to trauma regardless of the severity and mechanism of injury. The alveoli can rupture, causing a pneumothorax. Larger injuries can result in a continued air leak. The lung parenchyma can bleed causing a hemothorax or the architecture can be disrupted as with a pulmonary contusion. The chest wall, especially the intercostal and mammary arteries, may bleed when injured, as there is limited tissue to provide tamponade. Any of these injuries can range from relatively trivial to life-threatening.

Very large pneumothoraces produce tension by shifting the mediastinal structures toward the contralateral side with ...