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  • Despite frequent emphasis on devastating injuries, the most common thoracic injury is a chest wall contusion or rib fracture.

  • History, physical examination, and chest x-ray remain fundamental to the diagnosis of thoracic injury. Additional imaging, including extended focused ultrasonography assessment for trauma, computed tomography (CT) scanning, and CT angiography are frequently used.

  • A thoracostomy tube output of 1500 mL of blood on insertion or 200 mL of blood per hour usually warrants an urgent thoracotomy.

  • A left anterolateral thoracotomy through the third or fourth interspace allows exposure for opening the pericardium, open cardiac massage, clamping of the descending thoracic aorta, and treatment of a large percentage of cardiac and left lung injuries.

  • A retained hemothorax should be evacuated by video-assisted thoracoscopy or thoracotomy as soon as diagnosed.

  • New technologies, such as retrograde endovascular balloon occlusion of the aorta and extracorporeal cardiopulmonary resuscitation, have the potential to further change the philosophy of prehospital management for thoracic injuries.


Thoracic injury occurs in 20% to 25% of trauma patients, resulting in 16,000 deaths annually in the United States.1,2 Because the chest accounts for 25% of the total body mass, it is susceptible to injury from virtually any etiology or mechanism. Injury to the chest and its organs may be caused by penetration (missiles, fragments, knives, needles, and other objects), blunt forces, sudden deceleration, iatrogenic misadventure, blasts, and ingestion of toxic substances. Each of these etiologies has differing initial manifestations as well as evaluation and treatment approaches.3-5 These differences are more specifically discussed in other chapters of this textbook.

Despite frequent emphasis on devastating injuries, such as cardiac or great vessel injury, the most common thoracic injury is a chest wall contusion or rib fracture.2 Injuries to the heart or lungs frequently present with obvious signs that require prompt intervention. Some injuries, however, are less apparent and present with delayed manifestations requiring ongoing clinical suspicion and management. Consequently, patients with thoracic trauma require logical and sequential evaluation, followed by focused therapy, which involves an operation less than 20% of the time. Notably, the most common operation in a patient with a chest injury is an exploratory laparotomy, with formal thoracotomy a rare intervention. The objective of this chapter is to review the diagnostic process and judgment decisions leading to performing a thoracotomy in the trauma patient.


Initial evaluation follows the standard Advanced Trauma Life Support (ATLS) protocols. Physical examination should carefully evaluate for presence or absence of breath sounds or diminished breath sounds, presence of chest wall contusions, penetrating injuries, flail chest segments, and evidence of prior thoracic surgery (ie, sternotomy or thoracotomy incision scars). Upper and lower extremity pulse examination is essential and may be a marker of injury to the thoracic aorta or subclavian artery. Finally, the presence of cardiac murmurs or diminished ...

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