By Julia Saleh, MD, and Jessica Zhen, MD

Executive Summary

• Massive hemorrhage is the most common cause of preventable death after trauma, with recent modifications to the order of assessment including evaluating for exsanguinating hemorrhage as the first step, especially in the field, changing the algorithm to xABCDE, with “x” for exsanguination. The military implements a similar approach using the MARCH process: massive hemorrhage, airway, respiration, circulation, and hypothermia/head injury.
• Rib nerve blocks, including intercostal, erector spinae, serratus anterior, and rhomboid intercostal blocks, significantly reduce pain scores and opioid requirements in patients with rib fractures, particularly within the first 24 hours after block placement. These techniques are associated with improved pulmonary function and diaphragmatic excursion in the acute period.
• For the management of simple traumatic pneumothorax, hemodynamically stable patients may be observed with supplemental oxygen if the pneumothorax is less than or equal to 35 mm on computed tomography imaging or < 20% of the hemithorax on chest X-ray.
• Definitive management options include early video-assisted thoracoscopic surgery (VATS) for evacuation of retained hemothorax. Studies suggest that performing VATS within the first week is associated with reduced pulmonary morbidity and shorter hospitalization.
• Management of traumatic pericardial tamponade is emergent pericardial decompression, preferably echocardiography-guided pericardiocentesis. Echocardiography-guided pericardiocentesis is first-line with high success and low complication rates as reported by the American Society of Echocardiography.
• Managing patients with blunt aortic injury includes early surgical repair to decrease the risk of sudden rupture and death. In the emergency department, carefully managing the patient’s blood pressure and heart rate is necessary until definitive surgical repair. Systolic blood pressure should be maintained between 100 mmHg and 120 mmHg with medications like nicardipine or clevidipine, and heart rate should be maintained at 60 bpm.

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Early detection and prompt management of chest trauma is essential for the survival and optimal outcome for trauma patients. The authors provide the current status of diagnostic and therapeutic modalities for the management of a patient who has sustained chest trauma.

— Ann M. Dietrich, MD, Editor

Deaths within the first 30 to 180 minutes resulting from thoracic trauma may be prevented with the early identification and intervention by clinicians. Within the trauma surgery community, the most immediate life-threatening chest injuries are referred to as the lethal six: airway obstruction, tension pneumothorax, cardiac tamponade, open pneumothorax, massive hemothorax, and flail chest. In addition, there are other less-mentioned pathologies, often referred to as the hidden six, to be discussed later. It is estimated that only 10% of thoracic trauma patients will require surgical operation, and up to 90% can be treated with methods such as airway management, oxygen support, fluid resuscitation, and tube thoracostomy. These initial interventions involve first responders, nurses, and emergency clinicians, and are methods that emergency staff should be well-versed in their performance.^1,2 Patient care issues are predominantly related to difficulty managing the airway, fluid resuscitation, and the prompt recognition of chest injury. Early identification and intervention of these lethal pathologies remain goals of advancing clinical practice.

Initial Assessment

Initial, systematic assessment of a trauma patient is important, since it can be easy to miss subtle injuries in the setting of distracting major trauma. It is easy for injuries to be missed by first responders in the chaos of the field, and often trauma patients present on their own. In these instances, there is no trauma alert, and sometimes nursing staff may even be the first to evaluate the patient. Therefore, it is essential to be facile with the Advanced Trauma Life Support (ATLS) primary and secondary assessments. The ATLS primary survey is a systematic evaluation designed to identify and immediately treat life-threatening injuries. The primary survey follows the ABCDE approach:

• A: Airway with cervical spine protection. This can be done by asking the patient what their name is and paying attention to the quality of speech.
• B: Breathing and ventilation. Auscultate the chest and visualize chest movement to ensure symmetry.
• C: Circulation with hemorrhage control. Assess pulses, blood pressure, and signs of shock; control any active bleeding.
• D: Disability, neurological status. Assess their Glasgow Coma Scale score, pupil response, and motor function.
• E: Exposure and environmental control. Fully expose the patient; provide a warm blanket to prevent hypothermia.

It should be noted that massive hemorrhage is the most common cause of preventable death after trauma, and while the ATLS survey addresses this, there have been more recent modifications to the order of assessment. Now it is recommended to evaluate for exsanguinating hemorrhage as the first step, especially in the field, changing the algorithm to xABCDE, with “x” for exsanguination. The military implements a similar approach using the MARCH process: massive hemorrhage, airway, respiration, circulation, and hypothermia/head injury.

Accidents or unintentional injuries are the third leading cause of death in the United States.³ Thoracic trauma accounts for up to 35% of trauma-related deaths in the United States.⁴ Motor vehicle collisions are the most common cause of blunt chest trauma (BCT), which accounts for approximately 80%. Falls, pedestrians vs. vehicles, and blast injuries are other causes of BCT. Penetrating injuries, including gunshots and stabbings, account for the majority of the remaining thoracic injuries. The Centers for Disease Control and Prevention (CDC) reports that in 2022, there were 44,434 motor vehicle traffic deaths and 48,204 firearm-related deaths.⁵ As discussed in the introduction, up to 90% of thoracic injuries require simple methods, including tube thoracostomy and fluid resuscitation, measures that could be life-saving and require early recognition from emergency medicine providers, including physicians, nurses, and mid-levels who may be the first people to see a trauma patient.

Blunt thoracic trauma involves compression, crushing, acceleration, and/or deceleration injuries to the thoracic cavity, which can result in injuries to the chest wall, ribs, lungs, heart, aorta, trachea and respiratory branches, and/or diaphragm.² Penetrating traumas that are disruptive to the tissue commonly involve gunshot wounds and cutting mechanisms.

Chest Wall Injuries: Rib Fractures

Although rib fractures generally are self-limited, non-surgical, and will heal with time and supportive measures, there are important complications to consider, including pneumothorax, hemothorax, pulmonary contusions, and post-traumatic pneumonia. Flail chest is critical to identify because it is indicative of a more severe mechanism of injury and potential underlying injuries, and often is surgical. When three or more adjacent ribs are broken at two points, it creates a flail segment that results in paradoxical motion; the segment moves in with inspiration rather than out. It is important to note that it also can occur in the setting of a sternal fracture in combination with rib fractures. (See Figure 1.) This ultimately interferes with the physiology of respiration, often demonstrated by dyspnea, tachycardia, hypoxemia, and pain. Fractures can create sharp points that can penetrate the surrounding organs and/or tissue, which can lead to pain, bleeding, and perforation of organs, causing significant morbidity and mortality risk. Patients who have suspected rib fractures often complain of point tenderness and may even have bony crepitus or skin changes over the suspected rib.

Rib fractures may be a clinical diagnosis; however, if the injury is significant enough to raise concerns for other injuries, imaging should be obtained. Anteroposterior X-rays typically are the initial imaging modality used in the trauma bay because of ease; however, sensitivity is as low as 50% in some studies. For injuries that were classified as of major clinical significance, chest X-ray had a sensitivity of 75.4%. Major injuries missed included pneumothorax, spinal fractures, and hemothorax. The most commonly missed minor injuries included rib fractures, pulmonary contusions, and sternal fractures.⁶ If there is suspicion of a more serious injury, multiple rib fractures, or if the patient is high risk because of the mechanism or risk for complications, computed tomography (CT) imaging is the preferred modality. Sensitivity is around 80% to 82% and specificity is as high as 99.7% to 99.8%. Newer advancements with artificial intelligence (AI) assistance can raise sensitivity to 92%.⁷ Using clinical decision tools such as the NEXUS-Chest CT Criteria can be helpful for determining the necessity for CT imaging.

Differential diagnoses for rib fractures can range from costocondylar separation to rib contusion, but the cannot-miss diagnoses include sternal fracture, pulmonary injuries, tracheobronchial injuries, cardiovascular injuries, and esophageal injuries. The management of rib fractures is based on ensuring adequate pain relief and maintenance of pulmonary function. Multimodal pain modalities may include opioid and non-opioid analgesics and both oral and topical agents. Emphasizing deep breathing is important in the prevention of complications such as pneumonia. Whether patients are admitted to the hospital or discharged, they should receive an incentive spirometer device and be instructed in the ED on how to use it.

The greater the number of fractures, the greater the morbidity and mortality. Hospitalization should be considered for those with three or more rib fractures, polytraumatic injuries, and severe injuries, as mentioned earlier. Older adult patients with six or more rib fractures would benefit from intensive care unit (ICU) admission because of the propensity for complications. The RibScore is a clinical decision tool that can help guide the need for admission, while the Sequential Clinical Assessment of Respiratory Function (SCARF) Score helps assess pain management in patients with rib fractures and the need for potential escalation to opioids.

Updates on Rib Fractures

Nerve blocks with sodium-channel blockers once were thought to be exclusive to anesthesiologists; however, more emergency medicine providers are becoming certified in performing nerve blocks. Studies show that rib nerve blocks, including intercostal, erector spinae, serratus anterior, and rhomboid intercostal blocks, significantly reduce pain scores and opioid requirements in patients with rib fractures, particularly within the first 24 hours after block placement. These techniques are associated with improved pulmonary function and diaphragmatic excursion in the acute period.⁸

Surgical fixation regarding rib fractures typically was seen as the last line in management. Newer literature suggests that surgical fixation in appropriately selected older adults with flail chest leads to reduced mortality, shorter duration of mechanical ventilation, and decreased ICU and hospital costs. This emphasizes the importance of early consultation and transfer to a trauma center with surgical capabilities.⁹

Chest Wall Injuries: Sternal Fractures

Sternal fractures include any break in the sternal bone. Patients may present with localized anterior chest pain, swelling, and sometimes palpable deformity or crepitus. Displaced sternal fractures may lead to abnormal electrocardiogram (ECG) findings and elevated cardiac biomarkers. CT imaging of the chest is more sensitive and specific than conventional radiographs and may provide information about surrounding structures, including the heart, aorta, etc.¹⁰ Rare but important complications can include respiratory compromise, myocardial contusion, pneumonia, respiratory failure, and mortality. A majority of sternal fractures (> 95%) are managed nonoperatively with multimodal analgesia and pulmonary care, including incentive spirometry and early mobilization.¹¹

Surgical stabilization may be considered for more severe injuries and has been associated with improved respiratory function, decreased opioid requirements, and enhanced long-term quality of life in select patients.^12,13 In patients with isolated sternal fractures, normal ECG and troponin, and no hemodynamic instability can be discharged home.¹⁴ Hospitalization should be reserved for those with displaced fractures, multisystem trauma, abnormal cardiac findings, complex analgesic needs, or inadequate domestic support.¹⁵

Pulmonary Injuries

Pneumothorax

Pneumothorax is the accumulation of air in the pleural space. It can be caused by direct parietal or visceral pleural disruption from chest wall injury, such as a displaced rib fracture. Alveolar rupture from blunt compression-decompression can cause a sudden rise in intra-alveolar pressure, leading to alveolar tears that then dissect into the pleural space. In high-energy blunt or penetrating traumas, tracheobronchial injury can create a direct air leak into the pleural space. Overall, the result is intrapleural air accumulation that uncouples the lung from the chest wall. In patients with significant blunt chest trauma, the incidence of pneumothorax ranges from 5% to 26%.¹⁶ Shortness of breath and chest pain are common presenting complaints of pneumothorax. Auscultation may reveal decreased or absent breath sounds on the involved side. A simple pneumothorax occurs when it is closed and there is no communication with the atmosphere or any shift in the mediastinum or hemidiaphragm.

Initial imaging should be an upright film or CT imaging. However, many times trauma patients are in a cervical collar, on backboards, or under spinal precautions, so the X-rays typically are performed with the patients in the supine position, making small to even moderate pneumothoraces difficult to detect. Similarly, while CT is quite efficient for detection, it cannot be done as quickly. Therefore, ultrasound is being used more widely in emergency departments as part of the extended Focused Assessment with Sonography in Trauma (e-FAST) examination to detect pneumothorax. Using the phased array or liner probe longitudinally between two ribs, with the patient in a supine position, the absence of lung slide indicates a pneumothorax. Applying motion mode (M-mode) can help elucidate, with the “sandy beach” being normal lung movement and the “barcode” sign indicating pneumothorax.

For the management of simple traumatic pneumothorax, hemodynamically stable patients may be observed with supplemental oxygen if the pneumothorax is less than or equal to 35 mm on CT imaging or less than 20% of the hemithorax on chest X-ray.¹⁷

Communicating pneumothorax is associated with defects in the chest wall, typically a stab or gunshot wound. The loss in chest wall integrity leads to the involved lung paradoxically collapsing on inspiration and expanding on expiration, forcing air in and out of the wound. This is commonly known as the sucking chest wound. Communicating pneumothoraces should be covered with a three-sided occlusive seal until tube thoracostomy can be performed.

Tension pneumothorax results when the progressive accumulation of air under pressure within the pleural cavity causes a shift of the mediastinum to the opposite hemithorax and leads to compression of the contralateral lung and the great vessels. (See Figure 2.) The resulting shift compresses the vena cava, leading to decreased filling of the heart and decreased cardiac output. This results in the rapid onset of hypoxia and obstructive shock, which will be defined under the “Acute Pericardial Tamponade” section. Signs of tension pneumothorax include tachycardia, hypotension, oxygen desaturation, tracheal deviation, jugular venous distention, and absent lung sounds on the ipsilateral side.

Management is immediate decompression without waiting for imaging, followed by definitive chest tube placement, classically with a large bore chest tube. Immediate decompression may consist of finger thoracostomy or needle decompression. Finger thoracostomy consists of first identifying the insertion site. The standard location is the fifth intercostal space in the anterior axillary line, above the superior border of the inferior rib. If time and situation allow, the area is prepped using aseptic technique and then using a scalpel; a horizontal incision of approximately 3 cm is made. Blunt dissection then is performed using a curved clamp to dissect through subcutaneous tissue and the intercostal muscles until the parietal pleura is reached then entered. A gloved finger then is inserted into the pleural space to confirm entry and evacuate air or blood and sweeping for adhesions. The finger should be kept in place until a chest tube can be inserted and a three-sided occlusive dressing can be placed, and proceed resuscitating the patient.

For tension pneumothorax, needle decompression consists of inserting a large-bore needle into the chest wall to allow trapped air to escape from the pleural space. Classically, the anatomical site is the second intercostal space at the midclavicular line; however, recent evidence supports the fifth intercostal space at the anterior or mid-axillary line as an alternative, often with high accuracy.¹⁸

Becoming more popular even in emergent settings are “pigtail catheters” (a catheter significantly smaller in size than a traditional chest tube). The “pigtail” aspect comes from the coiled side inserted into the pleural space, ideally making it more difficult to dislodge than a chest tube. The controversy of using pigtail catheters in the setting of trauma is that because of the smaller diameter, it is believed that the catheter will be more likely to become obstructed by clotted blood draining from the tube, and that in the setting of an emergency the tube will not be efficacious in relieving the pressure from a tension pneumothorax or massive hemothorax rapidly enough to correct for hemodynamic instability. A recently published meta-analysis demonstrates that, in the setting of trauma patients, the patients who received pigtail catheters are shown to have higher output volume than those who received a chest tube. Patients with pigtail catheters also were less likely to require video-assisted thoracic surgery (VATS). During VATS, a thoracoscope is inserted into a small incision to allow surgeons to see within the chest wall cavity.¹⁹ Of mention, in recent years, the American Association for the Surgery of Trauma recommends antibiotic use (cefazolin) in patients with chest tube placement in those with penetrating trauma or delayed drainage of retained hemothorax.²⁰

The disposition of patients with pneumothorax will depend on the type of pneumothorax, hemodynamics, and associated injuries. As discussed, a simple, small pneumothorax may be observed for three to six hours in the emergency department, observation unit, or hospital with repeat imaging and close monitoring of vital signs.²¹ If there is no increase in the size of the pneumothorax or change in clinical condition, the patient can be safely discharged home within 24-48 hours.

Larger pneumothoraces (> 20% on chest X-ray), and patients with respiratory compromise requiring oxygen will require tube thoracostomy with admission into the hospital, typically under the trauma service. Hemodynamically unstable patients or those with tension physiology will require chest tube placement and management, and likely admission into a critical care setting.

Hemothorax

Hemothorax is the accumulation of blood in the pleural space after blunt or penetrating trauma. Common complications include hypovolemic shock and reduced capacity for lung expansion. Bleeding typically occurs from injury to the intercostal or internal mammary arteries/veins. Common sources of injury include displaced ribs and sternal fractures. Parenchymal lung lacerations bleed via torn pulmonary vessels directly into the pleural cavity. Deep lung lacerations can generate massive hemothorax and hemorrhagic shock if not rapidly controlled. In high-energy mechanisms, injuries to the great vessels like the aorta and vena cava, heart, or diaphragmatic attachments can rapidly fill the pleural space.²² Clinical features depend on the rate and quantity of hemorrhage. Patients may present with respiratory distress, tachypnea, and hypoxia. Auscultation of the chest may reveal diminished breath sounds.

An upright chest radiograph usually is the initial imaging modality, since blood will pool and be more visible, but as discussed earlier this often is unable to be obtained in the trauma assessment setting. Findings on chest X-ray imaging include fluid blunting the angle between the lungs and the diaphragm, which typically requires 200 mL to 300 mL of fluid. CT angiography (CTA) is considered the most accurate test when identifying hemothorax and contrast extravasation.¹⁰ As discussed previously, e-FAST is used extensively by emergency department clinicians and can be used for rapid bedside detection and triage of hemothorax. For time-critical decision-making, e-FAST may be used in combination with chest radiography to guide immediate tube thoracostomy without waiting for CT in more critical patients.²³

As with pneumothorax, management of hemothorax depends primarily on patients’ hemodynamic stability. Unstable patients with signs of hemorrhagic shock require tube thoracostomy and resuscitation with blood products. If imaging is available, a hemothorax of 300 mL or more on CT merits drainage. For smaller hemothoraces of less than 300 mL on CT, observation with close monitoring and repeat imaging is considered safe in hemodynamically stable patients. However, this should be in coordination with and management by the trauma or cardiothoracic service.

Complications may include retained hemothorax, which is the incomplete evacuation and subsequent organization of pleural blood into fibrinous clots with surrounding pleural inflammation. This impedes drainage and creates a nidus for infection. Management includes initial tube thoracostomy, and consideration of a preprocedural antibiotic dose to reduce infectious complications. At the time of tube placement, thoracic irrigation with warm sterile saline may lower the rate of retained hemothorax and subsequent interventions.

Definitive management options include early video-assisted thoracoscopic surgery (VATS) for evacuation of retained hemothorax. Studies suggest that performing VATS within the first week is associated with reduced pulmonary morbidity and shorter hospitalization.^24,25 Admission is the recommended disposition of all patients with hemothorax to be monitored in an inpatient setting. Unfortunately, even with patients who are stable and have a small hemothorax on CT (< 300 mL), there is a nontrivial failure rate of up to 20% to 30%.²⁶ If initial drainage is > 1,500 mL, if drainage persists at a high rate (classically described as 200 mL per hour for four hours), or if the patient has continued hemodynamic instability, an operative thoracotomy is warranted.²⁷

Blunt Cardiac Trauma

Blunt cardiac injury typically involves high speeds and decelerations to the chest wall, which usually results from motor vehicle collisions; however, it also can involve a range of mechanisms, from falls to crush injuries, direct blows with weapons, blast injuries, etc. Figure 3 is a diagram of the mediastinal structures outlined, and some structures will be covered in more detail with the associated injury in the setting of trauma.

Acute Pericardial Tamponade

The underlying cause of pericardial tamponade is the accumulation of blood that acutely elevates intrapericardial pressure and impedes diastolic filling. In chest trauma, hemopericardium arises from myocardial chamber laceration, coronary or pericardial vessel bleeding, or sharp rib/sternal fragments that penetrate the pericardium. With an intact pericardial sac, rapid blood accumulation leads to a rise in pericardial pressure and hemodynamic collapse. The right ventricle is anterior and often is involved in both penetrating and blunt injuries.^28,29 Once pericardial pressure exceeds diastolic pressures, there is compression of the chambers, predominantly right-sided collapse, reduced venous return, and a marked decline in stroke volume and cardiac output. The classic clinical features are those of obstructive shock from rapidly rising pericardial pressure. Beck’s triad is the presence of hypotension with elevated jugular venous pressure and muffled heart sounds. Additional common findings are tachycardia, tachypnea/dyspnea, and oliguria from low output. A fall of systolic blood pressure with inspiration, otherwise known as pulsus paradoxus (> 10 mmHg), further supports the diagnosis. Other symptoms to look out for include dyspnea, chest pain, weakness, and occasional nausea or abdominal discomfort.

The preferred imaging modality for pericardial injury is transthoracic echocardiography (TTE). It is the first-line modality in suspected cardiac injury because it can rapidly assess hemopericardium and tamponade physiology, including visible right-sided chamber collapse.³⁰ Ideally, cardiac ultrasound can be performed quickly at the bedside, minimally interrupting resuscitation. In the detection of cardiac tamponade, ultrasound has high sensitivity and high specificity, often > 90% when characteristic signs are simultaneously present, particularly right atrium and right ventricular collapse with plethoric inferior vena cava (IVC) and respiratory inflow variation. (See Figure 4.)

The major complication of pericardial tamponade is the ischemic consequences of obstructive shock. Other complications will be discussed in the management of pericardial tamponade. Obstructive shock is a type of shock characterized by inadequate cardiac preload due to obstructed venous return. This emphasizes the importance of quick identification, and physicians and nurses alike should be comfortable in recognizing the clinical features, signs, and symptoms as discussed earlier.

Management of traumatic pericardial tamponade is emergent pericardial decompression, preferably echocardiography-guided pericardiocentesis. Echocardiography-guided pericardiocentesis is first-line with high success and low complication rates as reported by the American Society of Echocardiography.³¹ This involves using focused transesophageal echocardiogram (TEE) to find the largest, shallowest effusion as the point of entry. It is optimal to always resuscitate and watch vital signs, although the pericardiocentesis may need to precede resuscitation if needed emergently. The Seldinger technique is used to ensure the placement of a pigtail drainage catheter. In the setting of traumatic hemopericardium, urgent surgical consultation is necessary for definitive repair, and pericardiocentesis may serve as a temporizing measure. If pericardiocentesis is unsuccessful or the patient’s clinical status deteriorates, thoracotomy should be performed as quickly as possible. This allows for the best exposure of the heart and direct visualization of the pericardial sac to evacuate blood and repair any injuries to the myocardium. Trauma patients who develop pericardial tamponade will undergo surgery and ultimately ICU admission for close hemodynamic monitoring.

Myocardial Concussion

Myocardial concussion, also known as commotio cordis, describes blunt cardiac trauma that usually is caused by a direct blow to the midanterior chest. This, in turn, stuns the myocardium and results in brief dysrhythmia, hypotension, and loss of consciousness, and even can cause cardiac arrest. It is rare and usually involves young patients playing sports. In 2023, commotio cordis occurred in a nationally televised Buffalo Bills football game, leading to an increased awareness of the condition. It is thought to be caused by blunt trauma to the precordium during a narrow window of ventricular repolarization, triggering ventricular arrhythmia in an otherwise structurally normal heart.³² Similar to the R on T principle when using synchronized cardioversion vs. defibrillation. Patients typically will present in a field setting with sudden collapse.

Otherwise healthy individuals with blunt cardiac trauma who collapse and have a shockable rhythm can be presumed to have commotio cordis. These patients likely will undergo extensive testing to rule out other causes (hypertrophic cardiomyopathy, Wolff-Parkinson-White syndrome, etc.), but ultimately will have evidence of structural heart disease on echocardiography or CT. Laboratory findings, such as cardiac biomarkers like troponin, will be normal.

Management involves standard advanced cardiac life support (ACLS) algorithms, ideally with initiation of bystander cardiopulmonary resuscitation (CPR) and early defibrillation. Patients who survive dysrhythmia should be admitted for observation. Ideally admission would involve cardiology consultation and work during hospitalization. After this, patients may be discharged but strictly advised to avoid sports play until cleared by a cardiologist.³³

Myocardial Rupture

Myocardial rupture is a traumatic perforation of the chambers of the heart, ventricles, or atria. It also may include pericardial rupture or laceration, as well as rupture of the interatrial septum, interventricular septum, valves, papillary muscles, etc. The chambers are the most likely to be involved in cardiac rupture, with the right ventricle being the most common because of its anterior location within the thoracic cavity. Rupture occurs when there is closure of the outflow tract, and ventricular compression of blood-filled chambers leads to pressure buildup in the chamber and ultimately a tear in the chamber wall. Other mechanisms considered include direct laceration from a fractured rib or sternum, upward pressure from the abdominal viscera from blunt abdominal injury, deceleration shearing stresses, and complications of myocardial contusion.³⁴

Clinical features of those with myocardial ventricular rupture typically are those of cardiac tamponade or hemorrhagic shock. Patients usually present with rapid hemodynamic deterioration and often die on scene. Hypotension, obstructive cardiogenic shock, pulseless arrest, and findings of cardiac tamponade discussed earlier also may be presentations. Other findings include a possible ST elevation on ECG from pericardial irritation. For those with papillary muscle rupture, an acute, severe mitral regurgitation may be heard on cardiac auscultation.³⁵

TTE is the first-line diagnostic tool for diagnosis of myocardial rupture. If images are suboptimal, a transesophageal or cardiac CT is recommended if patient stability allows.³⁰ In combination with clinical features such as shock and jugular vein distention (JVD) in a patient with blunt chest trauma, this may suggest pericardial tamponade and/or tension pneumothorax, both of which can be assessed with ultrasound at the bedside. In the emergency department, treatment should be directed toward decompression of the cardiac tamponade and control of hemorrhage. This may be temporary until surgical correction. Emergency thoracotomy and pericardiotomy may be required if a patient is rapidly deteriorating or cardiac arrest occurs. If the lesion is visualized, finger occlusion, suture, staples, and/or insertion of a Foley catheter through the defect may help control bleeding. Remember that it is appropriate to undergo emergency thoracotomy in institutions with qualified surgeons. As discussed previously in the section on acute pericardial tamponade, these patients are ill and labile and will require close monitoring in the ICU.³⁴

Blunt Aortic Trauma

Blunt aortic injury usually results from high-velocity mechanisms with sudden decelerations secondary to motor vehicle collisions. Common sites of injury are the aortic isthmus and ascending aorta. The descending aorta is fixed and immobile due to the intercostal arteries and the ligamentum arteriosum. For this reason, in the setting of sudden deceleration, the aortic arch, which is more mobile, moves forward in a shearing force on the aortic isthmus. This shear force may provoke an aortic tear. Approximately 80% to 90% of aortic tears occur in the descending aorta at the isthmus, just distal to the left subclavian artery.¹ Less commonly, ruptures also may occur. Rupture of the ascending aorta distal to the aortic valve is thought to be caused by rapid deceleration and chest compression, leading to a sudden increase in intrathoracic pressure. Approximately 60% to 90% of patients with blunt aortic injury will die on scene or within a few hours.¹ The survival rates depend immensely on early resuscitation and the timeliness of diagnostic and therapeutic procedures. As such, it is important to identify early and quickly.

Blunt aortic injury should be considered in any moderate- to high-speed motor vehicle collision, especially those with severe blunt force trauma to the chest. Unfortunately, aortic injuries can present in many ways. Patients may have neurological symptoms, making medical providers suspect a head injury. This emphasizes the importance of checking peripheral pulses for any pulse deficits. The most common symptoms are sternal pain and pain between the scapulae. Sympathetic nerve fibers are found near the aortic isthmus and cause hypertension. A harsh systolic murmur may be auscultated. Chest X-rays may be a very quick tool in assessing an aortic injury. A widened mediastinum may be visualized and alert providers to the diagnosis. CT imaging is the gold standard test for blunt aortic injury and has close to 100% sensitivity and specificity with intravenous contrast.³⁶

Managing patients with blunt aortic injury includes early surgical repair to decrease the risk of sudden rupture and death. In the emergency department, carefully managing the patient’s blood pressure and heart rate is necessary until definitive surgical repair. Systolic blood pressure should be maintained between 100 mmHg and 120 mmHg with medications like nicardipine or clevidipine, and heart rate should be maintained at 60 bpm. Esmolol is used for heart control and can be initiated as a bolus of 0.05 mg/kg over one minute, then infused at 0.05 mg/kg/min, titrated up by 0.05 mg/kg/min until a maximum of 0.3 mg/kg/min. Definitive management may include open repair vs. endovascular repair. These patients will require stabilization until surgery and ICU admission.³⁷

Traumatic Esophageal Injury

Esophageal injury secondary to trauma is extremely rare because of the protected posterior position of the esophagus. Some data suggest that traumatic esophageal injury occurred in 16 per 100,000 blunt trauma patients and overall 37 per 100,000 in all trauma causes.³⁸ Cervical esophageal injuries are most common due to a lack of protection from the thorax. Patients usually will have a tracheal injury as well, which is why the esophagus is overlooked. Clinical signs to be aware of include crepitus of the neck/chest wall, auscultation of “crunching sounds,“ dysphagia, dyspnea, etc. If the patient is stable enough, a preoperative esophagogram with water-soluble contrast should precede endoscopy. Operative repair is indicated in a majority of these injuries and should be done quickly to prevent complications, including mediastinitis, fistula, and abscess formation. Patients should receive broad-spectrum antibiotics if this diagnosis is suspected.

Traumatic Diaphragmatic Injury

Diaphragmatic rupture is identified in approximately 0.3% to 0.8% of all trauma patients.³⁹ A majority of cases of diaphragmatic rupture secondary to blunt trauma occur on the left side because the right side is protected by the liver. With penetrating trauma, this injury can occur at any site. In the setting of blunt trauma, the increased pressure within the abdomen typically is what causes the initial diaphragmatic tear. Because of the difference in intra-thoracic pressure and abdominal pressure, this leads to herniation of abdominal organs into the thoracic cavity.

Patients may be asymptomatic or have compressive-like symptoms ranging from vomiting, shortness of breath, or referred pain, or severe injuries such as multiorgan failure secondary to organ obstruction, strangulation, or perforation. If the tear is small enough, patients may go undiagnosed for years. CT imaging is the preferred initial imaging. A CT scan will miss some cases, and diagnostic laparoscopy and thoracoscopy may be indicated depending on the clinical situation or index suspicion for this injury. Patients found to have diaphragmatic injuries should undergo surgical repair, and so early surgical consultation is crucial.⁴⁰

Traumatic Tracheobronchial Injury

Tracheobronchial injury is rare in trauma patients, with an incidence of approximately 0.4%, and most cases following blunt trauma.⁴¹ Rapid anteroposterior chest compression with a closed glottis increases the tracheobronchial pressure against the carina and can lead to tears, typically within 2 cm of the carina or at the mainstem bronchi. Shear forces may occur at points of fixation, like the cricoid and the carina, during deceleration, causing lacerations. Lung traction from the rib cage deformity or a mediastinal shift can avulse the main bronchus. Other injuries can occur through direct bony lacerations. Overall, this can lead to air leakage into the mediastinum and the pleural cavity, potentially leading to pneumomediastinum and pneumothorax, as well as loss of airway continuity and ventilation-perfusion failure.⁴²

Patients with tracheobronchial injury often present with dyspnea, respiratory distress, stridor or wheezing, hypoxia, and ventilatory failure. Persistent air leak and difficulty ventilating when intubated should raise suspicion for these injuries. Patients may show signs of extensive subcutaneous emphysema in the neck, chest, and face, and pneumomediastinum may be visualized on imaging. Palpable crepitus under the skin can be felt. Complications include pneumothorax that reaccumulates despite proper chest tube placement and potentially tension physiology. This “intractable” or persistent pneumothorax is a clue, with continuous bubbling in the chest tube. Other signs and symptoms may include hemoptysis, bloody airway decreases, hoarseness in the voice, and neck/thoracic pain.⁴³ The preferred imaging choice in hemodynamically stable patients is a CT of the chest. Definitive diagnosis may be established with bronchoscopy.⁴⁴

Ideally, initial stabilization and airway management include securing a patent airway with endotracheal intubation distal to the lesion if feasible, preferentially under bronchoscopy guidance to avoid worsening the injury. Some emergency medicine physicians are comfortable with using bronchoscopy; otherwise, an appropriate consult may be made. In patients with severe hypoxemia or ventilation failure, extracorporeal membrane oxygenation (ECMO) can be a bridge to definitive repair. Early surgical repeat is the standard of care for most traumatic tracheobronchial injuries. Postoperative care should include monitoring for risks such as bronchial stenosis, infection, and need for pulmonary rehabilitation.⁴⁵

Recent Advancements: Imaging and Diagnosis

AI models are being integrated into identifying pathology on imaging more and more. AI models, particularly deep learning algorithms, have demonstrated high accuracy in identifying critical findings in chest trauma, such as pneumothorax, tension pneumothorax, rib fractures, pulmonary contusions, and hemothorax. For example, commercial AI models for chest radiographs can achieve sensitivities and specificities exceeding 90% for pneumothorax and tension pneumothorax and can flag findings for expedited review.⁴⁶ AI systems are shown to match or exceed diagnostic performance in non-radiology clinicians and, in some cases, radiology residents. This is particularly important in emergency settings without 24/7 radiology coverage.⁴⁷

Summary

Chest trauma is a significant contributor to trauma-related mortality, responsible for up to 35% of such deaths in the United States.⁴ Early deaths, often occurring within the first 30-180 minutes, frequently are preventable through rapid recognition and intervention, particularly for the six most lethal injuries: airway obstruction, tension pneumothorax, cardiac tamponade, open pneumothorax, massive hemothorax, and flail chest. (See Table 1.) Although only about 10% of patients require surgery, most can be managed with airway stabilization, oxygen support, fluid resuscitation, and tube thoracostomy. Initial assessment follows the ATLS ABCDE framework to identify and address life-threatening conditions systematically. Major injury patterns include rib fractures, which can lead to pneumothorax, hemothorax, and pneumonia; pulmonary injuries, such as pneumothorax and hemothorax; blunt cardiac injuries, including tamponade, commotio cordis, and myocardial rupture; vascular injuries like blunt aortic trauma; and rarer injuries, such as esophageal, diaphragmatic, and tracheobronchial trauma.

Diagnostic strategies rely on clinical evaluation supported by imaging — often chest radiography, CT, and, increasingly, point-of-care ultrasound — with AI emerging as a potentially powerful tool for rapid detection in resource-limited settings.

Management priorities depend on hemodynamic stability, ranging from observation for minor injuries to urgent decompression, surgical repair, or critical care admission for unstable patients. Recent updates emphasize the role of small-bore pigtail catheters as an effective alternative to large chest tubes, the increasing use of rib nerve blocks to improve pain control and pulmonary function, and evidence supporting early surgical fixation of flail chest in select patients to reduce mortality and hospital stay. These advances, combined with timely, systematic assessment, are critical in improving outcomes for patients with chest trauma.

Julia Saleh, MD, is an emergency medicine resident, Boonshoft School of Medicine, Wright State University, Dayton, OH.

Jessica Zhen, MD, is Assistant Professor, Emergency Medicine, Boonshoft School of Medicine, Wright State University, Dayton, OH.

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