Beyond the Basics: Thoracic Trauma

Thoracic injuries can be very dramatic, or exhibit subtle signs and symptoms that can be easily missed initially.

CEU Review Form Thoracic Trauma (PDF)Valid until August 3, 2007

     Thoracic injuries can be very dramatic, and may present with obvious physical findings that lead to immediate identification and management during the initial and rapid trauma assessment. For example, a large open wound to the anterior thorax can be easily found upon inspection of the supine patient in a well-lit environment. On the other hand, some patients with thoracic injuries may exhibit subtle signs and symptoms that can be easily missed initially, due partly to the extremely uncontrolled environment in which EMS personnel function. A small gunshot or stab wound to the thorax can be missed when assessing a patient in a poorly lit and chaotic setting. Accurate assessment requiring differentiation of breath sounds can also be hampered by loud background noises produced by crowds, music, television, passing vehicles or your own ambulance engine. A high index of suspicion, accurate assessment and frequent reassessment are necessary to identify both the apparent and less obvious thoracic injuries that could lead to lethal consequences.

Mechanism of Injury
     Thoracic injury may result from both penetrating and blunt trauma. Penetrating trauma has a tendency to be more obvious in the initial phases of assessment, due to the presence of an open wound to the thoracic wall. External bleeding may or may not be present. The amount of external bleeding is not an indicator of the potential severity of internal bleeding associated with an underlying trauma. High-velocity gunshot wounds and bullets that enter the thoracic cavity and ricochet can produce multiple organ, vascular and structural damage. The physical location of the gunshot entrance or exit wound does increase one's index of suspicion of underlying internal organ and structural damage; however, it does not provide a precise prediction of the complete scope of the internal injury. Low-velocity wounds to the chest, such as those produced by a knife, may better predict underlying organ and structural damage due to the kinematics associated with the injury.

     Blunt trauma may produce gross physical findings, such as large contusions, tenderness, fractured ribs and flail segments, or relatively little external evidence of injury. The chest wall may be severely compressed during the application of blunt force, causing the internal organs to be stretched, torn and sheared. After the blunt force is removed, the chest may recoil, leaving significant, moderate or minor evidence of the temporary cavitation that occurred during impact. If little external injury is evident, one may suspect minor or no internal thoracic damage; but, the patient may be suffering from multiple and severe organ, vascular and structural injury. In both cases, rely on patient complaints and physical exam findings to increase your index of suspicion of internal organ and structural injury.

     Blunt and penetrating trauma may produce injury to several structures within the thoracic cavity. Some injuries have a much higher incidence when associated with a specific mechanism, such as acute pericardial tamponade related to penetrating injury to the chest and upper abdomen, and esophageal injury associated with penetrating trauma to the neck and upper chest. Anatomical structures that have the potential to be injured in thoracic trauma are the chest wall, lung tissue, pulmonary tract, myocardium, great vessels (inferior and superior vena cava and aorta), esophagus and diaphragm. Thus, the injury may involve muscles, bones, organs and vessels.

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