Thoracic trauma

(Redirected from Thoracic Trauma)


Left pleura cavity (viewed from left) showing intercostal bundles (vein, artery, and nerve) under ribs.
  • Must determine if injury also traverses the diaphragm (intra-abdominal injury)
    • Most deaths in thoracic trauma patients are due to non-cardiothoracic injuries
  • Excessive positive pressure ventilation can lead to reduced venous return, tension pneumothorax (avoid excess bagging)
  • Place central lines on the SAME side as existing injury or pneumothorax (prevent bilateral pneumothorax)
  • Hypotensive resuscitation in chest trauma may be beneficial

Clinical Features


  • Seat-belt sign indicates possible deceleration or vascular injury
    • determine seatbelt placement (if worn improperly or abnormal body habitus)
  • Paradoxical wall movement indicates flail chest
  • Neck veins
  • Circulatory shock
  • Hemothorax
  • Swollen face
    • Conjunctival injection + facial edema + mechanism conducive to traumatic asphyxia may indicate SVC compression
      • also consider judicial/non-judicial hanging and strangulation
  • Subcutaneous emphysema
    • Anterior neck/supraclavicular
      • Tracheobronchial tree
      • Esophagus (Boerhaave's syndrome)
    • Chest wall
      • Visceral/parietal pleura


  • Neck
    • Trachea midline or displaced
  • Chest wall
    • Localized tenderness or crepitus due to rib fracture or subcutaneous emphysema
  • Sternum
    • Localized tenderness, crepitus, or mobile segment suggests fracture

Differential Diagnosis

Thoracic Trauma



  • Ultrasound
    • Can diagnosis hemothorax, pneumothorax, tamponade, rib fracture, sternum fracture
  • CXR
    • Can diagnosis hemothorax, pneumothorax, rib fracture, pulmonary contusion, diaphragmatic rupture
    • Frequently underestimates the severity/extent of chest trauma
  • CT
    • Gold-standard

Nexus chest CT in trauma rule (major injury)

CT if any one of the following:

  • Abnormal CXR
  • Distracting injury
  • Tenderness of:
    • Chest wall
    • Sternum
    • Thoracic spine
    • Scapula


  • 99% for major injuries
  • 90% for minor injuries


  • Treat underlying condition


  • Asymptomatic thoracic stab wound
    • Repeat CXR in 4-6hr; if no delayed pneumothorax seen, patient can be discharged
  • Disposition otherwise home, to OR, to ward, or to ICU depending on injuries



  • Common after severe trauma, especially if patient was unconscious at any time
  • Radiologic changes may be delayed up to 24hr (consolidation)
    • Due to chemical pneumonitis from gastric contents
  • No evidence to support prophylactic antibiotics to prevent pulmonary infection

Systemic air embolism

  • Patients with penetrating chest wounds who require PPV are at risk
  • May lead to dysrhythmias or CVA
  • Treatment
    • 100% NRB

See Also