Thoracic trauma: the deadly dozen.

Deadly Dozen ... Lethal Six ... Hidden Six ... Major thoracic injuries are known as the Deadly
Dozen. The Lethal Six (airway obstruction, tension pneumothorax, cardiac tamponade, open
pneumothorax, massive hemothorax, and flail chest) are immediate, life-threatening injuries that
require evaluation and treatment during primary survey. The Hidden Six (thoracic aortic
disruption, tracheobronchial disruption, myocardial contusion, traumatic diaphragmatic tear,
esophageal disruption, and pulmonary contusion) are potentially life-threatening injuries that
should be detected during secondary survey.
Early deaths, those that occur within 30 minutes to 3 hours, are due to cardiac tamponade, tension
pneumothorax, aspiration, or airway obstruction.' Although some of these injuries (most of them cardiac)
require emergent surgical intervention, most injuries to the lungs and pleura can be treated nonoperatively
by applying certain fundamental principles of initial trauma management, which can substantially reduce
morbidity and mortality related to these injuries.
AIRWAY OBSTRUCTION
The first priority in treating trauma patients is airway management. The cornerstones of airway
management are adequate oxygenation, ventilation, and protection from aspiration. Immediate airway
control can prevent death. Airway obstruction can be a primary problem or the result of other injury.
Initial priorities with all trauma patients are evaluation and management of the airway, breathing, and
circulation, cervical spine with stabilization, and level of consciousness.
The most common causes of airway obstruction are the tongue, avulsed teeth, dentures, secretions, and
blood. But, expanding hematomas that cause compression ofthe trachea, and thyroid cartilage or cricoid
fractures resulting in hemorrhage and edema may also be sources of obstruction. Airway compromise can
be acute, insidious, progressive, and/or recurrent. Bilateral mandibular fracture, expanding neck
haematoma producing deviation of the pharynx and mechanical compression of the trachea, laryngeal
trauma such as thyroid or cricoid fractures and tracheal injury include other causes of airway obstruction.
The single most frequent indication for intubation is an unconscious patient suffering compromised
ventilatory effort.
Key issues in managing airway difficulty include the following:
1. Delivering adequate oxygen to vital organs
2. Maintaining a patent airway
3. Ensuring adequate ventilation
4. Protecting the cervical spine
5. Recognizing the need for endotracheal intubation
6. Knowing how to utilize rapid sequence intubation
7. Being proficient in surgical airway techniques^
8. Preventing hypercarbia is critical!
Upon clinical evaluation, patients present with signs of anxiety, hoarseness, stridor, air hunger,
hypoventilation, use of accessory muscles, sternal and supraclavictilar retractions, diaphragmatic
breathing, altered mental status, apnea, and cyanosis (sign of preterminal hypoxia). Cyanosis is a very
late sign of preterminal hypoxia, since it requires at least 5 g of reduced hemoglobin to be clinically
detectable.
Indications for airway interventions are divided into 3 broad categories outlined in Table 1

Basic management for airway compromise includes

1. securing an intact airway,
2. protecting the airway if jeopardized, and
3. providing an airway if partially obstructed or totally obstructed.

Indications for surgical cricothyroidotomy are edema of the glottis, fracture of the larynx, or severe
hemorrhage obstructing the airway.

Flail Chest
Flail chest is traditionally described as the paradoxical movement of a segment of chest wall caused by
fractures of 3 or more ribs anteriorly and posteriorly within each rib. Variations include posterior flail
segments, anterior flail segments, and flail including the sternum with ribs on both sides of the thoracic
cage fractured. These fractures create a free-floating segment of rib or sterntim, resulting in a paradoxical
movement relative to the rest of the chest wall during inspiration and expiration. The segment follows
pleural pressure instead of respiratory muscle activity, which is sucked in during inspiration and protrudes
out during expiration. This movement may not be evident on initial assessment because intercostals
muscles in spasm act as a splint for the flail segment. This may be a contributing factor in the failure to
identify flail chest within the first 6 hours in up to 30% of patients with this injury.
Although the paradoxical motion of the unstable flail can greatly increase the work of breathing, the main
cause of hypoxetnia of flail chest is the underlying pulmonary contusion, which invariably occurs with
flail chest.'* Nonetheless, paradoxical movement prevents full expansion of the underlying lung,
decreasing minute ventilation. Pain is a contributing factor, preventing the patient from taking full
breaths.

The actual motion of the flail segment is usually limited by the surrounding structural components, the
intercostals, and the surrounding musculature. This mechanical limitation of motion affects the actual size
of the changes in thoracic volume and patient-generated tidal volume. Underlying pulmonary or cardiac
disease determines the physiologic perturbations to respiration caused by the flail segment.

Presentation
Flail chest is a clinical anatomic diagnosis noted in blunt trauma patients with paradoxical or reverse motion of
a chest wall segment while spontaneously breathing. This clinical finding disappears after intubation with
positive pressure ventilation, which occasionally results in a delayed diagnosis of the condition.
The strict definition of 3 ribs broken in 2 or more places can be confirmed only by x-ray, but the inherent
structural stability of the chest wall due to the ribs and intercostal muscles usually does not show abnormal or
paradoxical motion without 3 or more ribs involved. Patients may demonstrate only the paradoxical chest wall
motion, and they may have minimal to incapacitating respiratory insufficiency, although these individuals
usually show some tachypnea with a notable decrease in resting tidal volume due to fracture pain. The degree
of respiratory insufficiency is typically related to the underlying lung injury, rather than the chest wall
abnormality.

Patients with flail chest present with asymmetric chest movement and signs of respiratory distress, including

increased respiratory rate and work of breathing, and decreased tidal volumes. Crepitus may be palpated
around the flail segment, and patients will complain of chest pain. Over time, the patient fatigues and
requires mechanical ventilation to maintain adequate oxygenation and minute ventilation.

Relevant Anatomy
The chest wall is inherently stable, with 12 ribs attaching posteriorly to the spinal column and
anteriorly to the sternum. Intercostal muscles with fascial attachments, coupled with other muscle
groups, including the trapezius and the serratus groups, add further strength to the bony cage
around the thoracic organs. The arch design of the ribs allows for some flexing, more so in children
than adults, which can absorb small amounts of blunt kinetic energy. Crush or rollover injuries,
especially with heavy objects or significant deceleration injury commonly breaks a rib in 1 position,
but only a significant impact breaks a rib in 2 or more positions.

THE MANAGEMENT OF FLAIL CHEST

At present, most patients with isolated flail chest are admitted to a trauma
ICU and receive aggressive pulmonary toilet and pain control. In patients
with an isolated flail chest injury, adequate analgesia greatly facilitates
pulmonary toilet and early patient mobilization.
Epidural analgesia has proved extremely effective in managing the acute
pain from chest wall injury. Splinting and paradoxical chest wall motions are
improved to near normal levels. Epidural use improves pulmonary toilet by
enabling the patient to breathe deeply, cough effectively, and actively
participate in chest physiotherapy [2022]. Adverse effects, such as
hypotension in the underresuscitated patient, respiratory depression, and
epidural

infection, can limit its effectiveness [21]. In addition, epidurals can hinder
diagnosis of intraabdominal injuries in critically ill trauma patients [23].
Despite these potential
complications, epidural analgesia remains central in the management of flail
chest.
Thoracic paravertebral block is a technique whereby local anesthetic is
injected along the thoracic vertebrae. This modality provides ipsilateral
analgesia over a dermatomal distribution and, unlike epidural anesthesia,
minimizes hypotension secondary to a unilateral sympathetic blockade [24
26]. Nonsteroidal anti-inflammatory drugs, such as ketorolac and
indomethacin, are effective in the management of mild to moderate chest
wall pain. They are particularly useful when used as an adjunct to
patientcontrolled anesthesia or epidural analgesia. Nonsteroidal antiinflammatory drug use is limited in many trauma patients who may have
acute renal failure or stress gastric ulcers.
Mechanical ventilation is reserved for patients with persistent respiratory insufficiency or failure after
adequate pain control or when complications related to excessive narcotic use occur. Patientcontrolled analgesia (PCA) machines, oral pain medications, and indwelling epidural catheters form
the mainstay of current treatment.
Two recent clinical reports, one from Turkey (prospective) [9] and one from Japan (retrospective),
[10]
showed that continuous positive airway pressure (CPAP) by mask may decrease mortality and
nosocomial pneumonia in the ICU, but CPAP by mask does not appear to change the length of ICU
stay.

Surgical management
The surgical management of flail chest has traditionally been reserved for
the following indications: (1) patients with flail chest who require
thoracotomy for other intrathoracic injury, (2) those who are unable to be
successfully weaned from mechanical ventilatory assistance, (3) severe
chest wall instability, (4) persistent pain secondary to fracture malunion, and
(5) persistent or progressive loss of pulmonary function [40,41].
In a retrospective study involving 21 patients with flail chest who were admitted to a level I trauma
center between September 2009 and June 2010, Doben et al examined the effectiveness of surgical
rib fixation for patients in whom standard therapy had failed. Standard therapy consisted of pain
control, aggressive pulmonary hygiene, positive pressure therapy with an acapella device, and
frequent chest therapy (chest wall percussion, deep breathing, and coughing exercises). The
surgical rib fixation surgeries were performed via a standard anterolateral or posterolateral musclesparing thoracotomy incision; ribs were reduced and internally fixated through use of osteosyntheses
plates and intramedullary nails. Surgical rib fixation resulted in a significant decrease in ventilator
days (4.5 vs 16.0), and the authors concluded that the technique may represent a means to
decrease morbidity in patients with flail chest whose pulmonary status is declining.

Preoperative Details
Assessment of the severity of underlying pulmonary contusion versus chest wall instability should
direct the need for surgical fixation. Preoperatively, a double-lumen endotracheal tube should be
considered in patients with flail chest undergoing fixation.

Complications
Reports in the medical literature note a high level of long-term disability in patients sustaining flail
chest. Beal and Oreskovich reported a 22% disability rate with over 63% having long-term problems,
including persistent chest wall pain, deformity, and dyspnea on exertion. [18] Kishikawa et al, however,
noted resolution of altered pulmonary function within 6 months, even with chest wall deformity still
present.[19]

Outcome and Prognosis

Overall, patients with flail chest have a 5-10% reported mortality if they reach the hospital alive.
Patients who do not need mechanical ventilation do better statistically, and overall mortality seems to
increase with increasing injury severity scores (ISS), age, and number of total rib fractures.

Future and Controversies

Further improvements in emergency medical systems and the education of prehospital personnel
may increase the observed frequency of flail chest in the future. Improvements in noninvasive
ventilation techniques like CPAP and pain control may also improve currently observed outcomes.
Prevention, including safer automobiles and newer airbag design may affect the incidence and
outcome of these multifactorial injuries.

HEMOTHORAX/MASSIVE HEMOTHORAX

Hemothorax is the accumulation of blood in the pleural space caused by bleeding from the chest wall,
lung parenchyma, or major thoracic vessels. Patients with hemothorax typically present with decreased
breath sounds unilaterally or bilaterally with dyspnea, tachypnea, and dullness to percussion over the
affected side. The primary cause of hemothorax is either a laceration to the lung, an intercostal vessel, or
an internal mammary artery because of blunt or penetrating trauma. Bleeding in these types of cases is
usually self-Umiting and does not require surgical intervention. Radiographic films may not reveal a fluid
collection of less than 300 mL. Bleeding from parenchymal lacerations often stops on its own because of
the low pulmonary pressures and high concentrations of tissue thromboplastin in the lung.
Accumulation of greater than 1500 mL of blood is considered a massive hemothorax that can have
disastrous results. A left-sided massive hemothorax is more common than the right-sided one, and is
typically associated with aortic rupture.^ A massive hemothorax is commonly due to penetrating trauma
with hilar or systemic vessel disruption.