Sezione Medicina

da Leadership Medica n. 1 del 2000

Twenty-five percent of trauma-related deaths are associated with injuries to the thorax. The focus during the primary survey and resuscitation phases of such patients is the identification and correction of immediately life-threatening problems. 
General supportive measures include treatment of hypovolemia by fluid and cathecolamines infusion, recognition and drainage of hemo-pneumothorax, assessment of acute respiratory failure. 
Pulmonary contusion occurs in 30 to 40 % of patients sustaining thoracic trauma. Its treatment is supportive and depends upon the degree of pulmonary dysfunction: patients without severe respiratory failure, early pain control and chest physiotherapy  reduce the need for invasive mechanical ventilation. Standard mechanical ventilation (MV) can be contraindicated in case of severe unilateral pulmonary damage. In such cases independent lung ventilation is the treatment of choice.


Thorax trauma are extremely frequent in our country.
Recent data account that, in Italy, 5% of the admission to the intensive care are due to this pathology.(1)
In Usa  trauma of the thorax are 30% of the admissions in the Trauma center (2). The mortality related is high. On the accident site the mortality is 25%, while in Hospital mortality is 4-8% for isolated thorax trauma and 35% of patients with multiorgan damage (2).
The mortality has a triphasic pattern:
a) few minutes after the trauma, 
b) few hours afterwards for lesions potentially lethal, but curable if treated  during the so- called golden hour c) days or weeks afterwards due to complications.
In this last instance the treatment is essential in order to reduce the mortality.

Initial  treatment
The first aid of the trauma patient is  equal to the approach  to any critical patient.
Control of the respiratory airway must be obtained and ventilation, if necessary, must be promptly available (obstructed airway, pneumothorax, impaired mechanical ventilation)
Good vein access is mandatory and a neurologic assessment must be promptly performed.
Urgent surgical operation is rare in the thorax trauma.
After the aid is important to check for the presence of pulmonary and cardiovascular lesions that could develop also in the following days.

Instrumental examinations
The exams to be performed are: thorax x ray, ct scan, angiography, echocardiography and broncoscopy.
Thorax x ray is essential in order to evaluate the condition of the thorax cage, the presence air and fluid, the extension of the lung contusion.

Patients with a fracture of the first and second ribs has in 40% of the case a myocardial contusion or major vascular damage, while in the presence of fracture of the last three ribs a lesion of the liver or the spleen should be suspected.
Damage of the aorta could be shown with a mediastinal enlargement or a deviation  rightwards of the esophagus.
Echocardiography is extremely useful in the evaluation of this category of patients.

Trans esophageal echocardiography allows the cardiac chambers and the function of the heart. 
Moreover Tee  is very important to diagnose dissection and traumatic lesions of the aorta.
Ct scan is nowadays performed routinely, and is important to evaluate lesions and pathologies non apparent on the x ray.

Bronchoscopy is mandatory in all cases and particularly when exists a trauma of the airways.
The statistics reported in the literature show the importance of this exams and its reliability.
The percentage of false negative is very low, and this happens when the exam is performed in difficult condition. Bronchoscophy must be performed according to the radiological  and clinical picture of the patient.

Hemodinamic assessment 
The hemodinamic control of the patient is, of course, essential.
The choice of the fluid management and of the drugs is related to the clinical conditions of the patient(tab. 1); myocardial contusion  and neurogenic shock can cause hemodinamic impairment.

Tabella 1

A good way to deal with hypotension is a fluid infusion of 500-2000 ml/hrs.when blood loss is controlled.
If the pressure rises than the cause was hypovolemia otherwise other underlying mechanisms should be thought.
In the case of continuous blood loss or cardiac dysfunction  inotropic drugs should be instituted (tab. 2,3).

Resuscitation treatment
The admission rate to the intensive care is 25%. The main case of admission are: severe respiratory insufficiency and flail chest or associated lesions

Respiratory insufficiency
The variations of the respiration in the presence of flail chest has been described as "pendulluft". The air inspired goes  from the damaged lung to the other during inspiration, and viceversa during expiration (4). However this theory has been discussed  clinically and in the experimental setting (4).
The pain due to the presence of  flail chest can cause a superficial pattern of ventilation.
In this area of disventilation and athelectasia  can be originated in the underlying lung.
Lung contusion can reduce the lung compliance and to increase the ventilation mismatch.
Several factors are responsible of the alterated ventilation pattern in the presence of trauma of the chest.
The goal of the treatment is to counteract the different factors the influence the lung dynamic.
The main action should go toward a reduction of the pain, a correction of pneumothorax, and to reestablish a correct lung ventilation (6)
When the respiratory insufficiency persist mechanical ventilation should instituted.(7) 

Mechanical ventilation differentiated for the lung
The mechanical ventilation of the patients with trauma of the thorax is performed in the usual way.
Particular attention is needed in order to control the airway pressure allowing the closure of lesions. (2,4,5).
When only one lung is damaged the normal pattern of artificial ventilation can worsen the gas exchange (8,9).
The air ventilated goes preferentially to the healthy lung which has a normal compliance. In this instance a separated ventilation becomes mandatory.

Complication and prognosis
All the factors described play an important role in the developing of complications. And in the related prognosis.

Trauma of the thorax  is a dramatic event which has a high mortality.
The therapeutic  approach must be correctly instituted in order to diminish the rate of complications and the related mortality.

Gilda Cinnella
Ricercatore - Dipartimento dell'Emergenza e dei Trapianti d'Organo 
Sezione di Anestesia e Rianimazione -  Università di Bari


1. Apolone G, Brazzi L, Pesce C: Studio multicentrico sui profili di cura e sull'outcome di pazienti ricoverati in reparti di Terapia intensiva italiani. Minerva anestesiol 58:1297-1303, 1992.
2. Turney SZ, Rodriguez A, Cowley RA: Management of cardiothoracic trauma. Williams & Wilkins, Baltimore, 1990.
3. Riou B, Goarin JP, Saada M: Assessment of severe blunt thoracic trauma. In Yearbook of Intensive care and Emergency medicine. JL Vincent ed, 611-618, 1993.
4. Hood M: Postinjury and postoperative care of thoracic trauma. In Thoracic trauma, Hood MR, Boyd AD, Culliford AT, eds WB Saunders, 1989.
5. Johnson JA, Cogbil TH, Winga ER: Determinants of outcome after pulmonary contusion. J Trauma 26:695-697, 1986.
6. Cullen P, Model JH, Kirby ET, et al: Treatment of flail chest. Use of intermittent mandatory ventilation and positive end-expiratory pressure.  Arch Surg 19:355-363, 1975.
7. Mackersie RC, Shackford SR, Hoyt DB, et al: Continuous epidural fentanyl analgesia: ventilatory
8. Zandstra DF, Sthoutenbeck ChP, Bams JL: Monitoring lung mechanics and airway pressures durning differential lung ventilation with emphasis on weaning from DLV. Int Care Med 15:458-463, 1992.
9. Cinnella G, Maggiore SM, Fanelli G, Di Venosa N: Ventilazione polmonare differenziata nei traumi toracici. Atti XII simposio meridionale di Anestesiologia e Rianimazione, pp 152-158, 1998.