Thoracic Trauma: Current Approach in Emergency Medicine
Abstract
:1. Introduction
1.1. Initial Management, Primary and Secondary ATLS Survey
1.2. EFAST Ultrasound and Radiographic Diagnosis before Surgical Procedures
2. Emergency Department Thoracotomy
2.1. Indications
2.2. EDT versus REBOA for Non-Compressive Torso Hemorrhage
2.3. Procedure
2.4. Management of Specific Injuries
2.4.1. Blunt Thoracic Aortic Injury (BTAI)
2.4.2. Penetrating Thoracic Aortic Injury (PTAI)
2.4.3. Diaphragmatic Injuries and Video-Assisted Thoracoscopic Surgery (VATS)
2.5. Intrathoracic Injuries
2.6. Esophageal Injuries
3. Urgent Thoracotomy
Surgical Approaches
4. Urgent Exploratory Thoracotomy
5. Delayed Thoracotomy
6. Medico-Legal Implications of Thoracic Trauma
7. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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Type of Trauma | Sign and Symptomps | Diagnosis | Treatment |
---|---|---|---|
Cardiac injuries [5,43,44] | Pericardial tamponade, haemorrhagic shock. (mortality: 10–70%) | Pericardiocentesis. | Sternotomy |
Great vessels injuries [45,46,47,48,49] | Hemothorax, pericardial tamponade, pulseless, stroke, coma. | Thoracotomy, angiography, CT-angiography. | median sternotomy (subclavian or parasternal lesions; ascending aorta); posterolateral thoracotomy (subclavian artery; vertebral and mammary arteries); patch venography |
Pulmonary injuries [7,8,49,50,51,52,53,54,55,56,57,58,59] | Pneumothorax, hemothorax, shock. (mortality: 40–50%) | CT. | Chest tube; thoracotomy for anatomical lung resections; pneumonectomy |
Tracheobronchial injuries [60,61] | Subcutaneous emphysema, hemoptysis, stridor, respiratory distress, hypertensive pneumothorax, pneumomediastinum | Bronchoscopy, CT. | Thoracotomy; drain placement |
Esophageal injuries [42,44,62,63] | Hematemesis, odynophagia, dysphagia. | Chest X-ray, CT, surgical exploration, endoscopic examination. | Nasogastric tube position by endoscopy+ antibiotic cover; enteral feeding via feeding tube or nutritional support with TPN; cervicotomy; right posterolateral thoracotomy (upper and middle injuries); left posterolateral thoracotomy (distal injuries), esophageal deviation, esophageal exclusion, esophagectomy, T tube drainage, Endo-VAC therapy |
Traumatic rupture of the thoracic aorta [64,65,66,67] | There is no specific sign or symptom for such injuries. (mortality: 90%) | Chest X-ray, CT angiography | Beta blockers, endovascular stent, primary anastomosis requires cardiopulmonary bypass |
Site | Sternotomy | Right Thoracotomy | Left Thoracotomy |
---|---|---|---|
Right atrium | +++ | ++ | 0 |
Right ventricle | +++ | + | + |
Left atrium | +++ | + | + |
Left ventricle | ++ | 0 | +++ |
SVC | +++ | ++ | 0 |
Azygos vein | ++ | +++ | 0 |
IVC | +++ | ++ | 0 |
Aortic root | +++ | + | 0 |
Aortic arch | +++ | 0 | ++ |
Right subclavian | ++ | ++ | 0 |
Proximal right carotid | +++ | + | 0 |
Innominate | +++ | ++ | 0 |
Left subclavian | + | 0 | +++ |
Proximal left carotid | ++ | 0 | ++ |
Descending aorta | 0 | + | +++ |
Main PA | +++ | 0 | ++ |
Right PA | ++ | +++ | 0 |
Left PA | ++ | 0 | +++ |
Right UL | ++ | +++ | 0 |
Roght ML | ++ | +++ | 0 |
Right LL | + | +++ | 0 |
Left UL | + | 0 | +++ |
Left LL | 0 | 0 | +++ |
Right hilum | ++ | +++ | 0 |
Left hilum | ++ | 0 | +++ |
Pericardium | +++ | ++ | ++ |
Right IMA | ++ | +++ | 0 |
Left IMA | ++ | 0 | +++ |
Proximal esophagus | 0 | +++ | 0 |
Distal esophagus | 0 | ++ | +++ |
Proximal trachea | ++ | + | + |
Carina | 0 | +++ | + |
Right main stern | 0 | +++ | 0 |
Lest main stern | 0 | ++ | ++ |
Right hemidiaphragm | + | +++ | 0 |
Left hemidiaphragm | + | 0 | +++ |
CPB | +++ | ++ | ++ |
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Caputo, G.; Meda, S.; Piccioni, A.; Saviano, A.; Ojetti, V.; Savioli, G.; Piccini, G.B.; Ferrari, C.; Voza, A.; Pellegrini, L.; et al. Thoracic Trauma: Current Approach in Emergency Medicine. Clin. Pract. 2024, 14, 1869-1885. https://doi.org/10.3390/clinpract14050148
Caputo G, Meda S, Piccioni A, Saviano A, Ojetti V, Savioli G, Piccini GB, Ferrari C, Voza A, Pellegrini L, et al. Thoracic Trauma: Current Approach in Emergency Medicine. Clinics and Practice. 2024; 14(5):1869-1885. https://doi.org/10.3390/clinpract14050148
Chicago/Turabian StyleCaputo, Giorgia, Stefano Meda, Andrea Piccioni, Angela Saviano, Veronica Ojetti, Gabriele Savioli, Gaia Bavestrello Piccini, Chiara Ferrari, Antonio Voza, Lavinia Pellegrini, and et al. 2024. "Thoracic Trauma: Current Approach in Emergency Medicine" Clinics and Practice 14, no. 5: 1869-1885. https://doi.org/10.3390/clinpract14050148