Snapshot A 35-year-old man presents to the ED with a stab wound to the left chest lateral and above the nipple. The paramedics report that he had been writhing in pain in the ambulance. His blood pressure is 80/50 mmHg, pulse is 120/min, and respirations are 22/min. Tube thoracostomy is performed in the left chest at the fifth intercostal space. About 1500 ml of blood is evacuated immediately, but the patient continues to lose blood. Introduction Trauma to chest accounts for ~50% trauma mortality 80% of all chest injuries can be managed non-surgically with simple measures including intubation, chest tubes, and pain control Location and mechanism of injury determines acuity and management strategy Presentation Different chest trauma diagnoses can be identified and managed during primary and secondary survey Primary survey airway obstruction acute anxiety, stridor, hoarseness, altered mental status, apnea, cyanosis tension pneumothorax open pneumothorax massive hemothorax flail chest cardiac tamponade Secondary survey pulmonary contusion blunt trauma to chest causing interstitial edema that impairs compliance and gas exchange ruptured diaphragm blunt trauma to chest or abdomen esophageal injury usually due to penetrating trauma pain out of proportion to degree of injury do NOT use barium as it is caustic - gastrograffin is preferred aortic tear 90% of cases tear at subclavian artery near ligamentum arteriosum most die at scene blunt myocardial injury STUDIES Diseases suspected in primary survey diagnoses are primarily clinically based on history and exam rapid workup can include arterial blood gas, CXR, bedside ultrasound (FAST) Diseases suspected in secondary survey pulmonary contusion CXR: opacification of lung within 6 hours respiratory decompensation ruptured diaphragm CXR: abnormal peridiaphragmatic anatomy CT scan and endoscopy if further workup needed esophageal injury CXR: potential pneumomediastinum esophagram/esophagoscopy aortic tear CXR, CT scan, TEE CT aortography (gold standard) blunt myocardial injury dysrhythmias, ST changes Management Airway management: intubate early if airway compromise suspected Needle thoracostomy use large bore needle at 2nd intercostal space in midclavicular line best initial step in management of tension pneumothorax Tube thoracostomy chest tube at 5th intercostal space in anterior axillary line next step in management after needle placement in tension pneumothorax Oxygenation positive pressure ventilation for flail chest Circulation IV crystalloids early for management of hemodynamic instability transfusion for significant blood loss Thoracotomy indications > 1500 ml total blood loss > 200 ml/h continued drainage of blood for > 3 hours Surgical repair as needed