Initial Evaluation and Management of Penetrating Thoracic Trauma in Adults - UpToDate PDF

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Initial evaluation and management of penetrating thoracic

trauma in adults
Authors: Julie M Winkle, MD, FACEP, FCCM, Eric Legome, MD
Section Editor: Maria E Moreira, MD
Deputy Editor: Jonathan Grayzel, MD, FAAEM
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jun 2019. | This topic last updated: Apr 12, 2019.
INTRODUCTION
The presentation of penetrating thoracic trauma can vary widely, from stable patients with few
complaints to hemodynamically unstable patients requiring immediate life-saving interventions. Even
apparently stable patients with penetrating chest injuries can deteriorate precipitously and a focused
evaluation must be rapidly performed to assess for life-threatening conditions.
This topic review will discuss the epidemiology, mechanisms, and general approach to the initial
management of injuries sustained by adults with penetrating thoracic trauma. Blunt thoracic trauma,
thoracic trauma in children, and definitive management of specific injuries are reviewed separately.
(See "Initial evaluation and management of blunt thoracic trauma in adults" and "Thoracic trauma in
children: Initial stabilization and evaluation".)
EPIDEMIOLOGY
Penetrating chest trauma is generally less common but more deadly than blunt chest trauma.
According to small retrospective reviews, chest injuries are a relatively common cause of preventable
death among trauma patients [1,2]. Thoracic wall penetration occurs most often from gunshots and
stabbings, which comprise up to 10 and 9.5 percent, respectively, of all major trauma in the United
States [3]. Other causes of penetrating thoracic injury include being impaled by objects as a result of
industrial accidents, falls, collisions, blast injuries, and fragmenting military devices.
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The incidence of penetrating thoracic trauma varies geographically. In the United States, 9 percent of
all trauma related deaths occur from injuries to the thorax, of which one-third involve a penetrating
mechanism [4,5]. In Europe, the incidence of penetrating trauma is reported to be as low as 4 percent
[6]. However, in countries or regions engaged in warfare, up to 95 percent of military deaths may
result from a penetrating mechanism [7]. Urban centers tend to have higher rates of interpersonal
violence and a correspondingly higher percentage of injuries involve penetrating mechanisms
compared to rural regions.
Most penetrating chest injuries do not require major operative intervention and many patients are
managed with observation and serial evaluation using radiography or simple tube thoracostomy.
Approximately 15 to 30 percent of penetrating thoracic injuries require surgery, as opposed to less
than 10 percent of injuries from blunt chest trauma.
The exact incidence of specific wounds incurred from penetrating thoracic trauma is difficult to
determine. Major vascular injuries occur in approximately 4 percent of patients with penetrating chest
injuries. Penetrating tracheobronchial wounds are associated with concurrent esophageal and major
vascular injures in approximately 30 percent of cases [8]. Cardiac injuries are sustained by 3 percent
of patients with penetrating tracheobronchial wounds and are associated with high mortality.
The incidence of diaphragm injuries associated with penetrating trauma to the thoracoabdominal area
is reported to be 11 to 19 percent [9-11]. This number increases to approximately 30 percent for stab
wounds and 60 percent for gunshot wounds isolated to the left lower chest. Injuries to the diaphragm
may be difficult to diagnose, as up to 31 percent of patients may demonstrate no abdominal
tenderness and 40 percent may have normal chest radiographs. Among all asymptomatic patients
with penetrating chest injuries, the risk of occult diaphragm injury is reported to be 7 percent [12]. If
undiagnosed, diaphragm injury is associated with a high risk of bowel herniation. (See "Recognition
and management of diaphragmatic injury in adults".)
ANATOMY, PATHOPHYSIOLOGY, AND MECHANISM
The thoracic structures at risk from penetrating chest trauma include the chest wall, lungs,
tracheobronchial tree, heart, aorta and thoracic great vessels, esophagus, diaphragm, spinal cord,
thoracic vertebrae, and the thoracic duct. Thoracic anatomy is reviewed separately; elements of
particular relevance to penetrating trauma are discussed below. (See "Initial evaluation and
management of blunt thoracic trauma in adults", section on 'Anatomy and mechanism'.)
Common mechanisms and associated injuries by location
● Chest wall – By definition, penetrating chest trauma violates the chest wall. However, depending
upon the mechanism, penetrating trauma often causes less significant injury than blunt trauma.
Low-energy mechanisms, such as stab wounds, rarely cause important injuries to the chest wall,
with the exception of intercostal artery lacerations or single rib fractures. High-energy shotgun
wounds can cause significant bony and soft tissue damage that may affect the stability of the
chest wall leading to difficulties with ventilation. (See "Initial evaluation and management of chest
wall trauma in adults".)
● Lungs – Lung injuries from penetrating trauma may include pneumothorax, pulmonary
contusion, hemothorax, pulmonary laceration, or a combination thereof. Pneumothorax occurs in
the great majority of patients with transpleural penetrating chest injuries. Pneumothorax is
discussed in detail separately. (See "Placement and management of thoracostomy tubes and
catheters in adults and children".)
Pulmonary contusion is a common injury after high-energy penetrating chest trauma [13]. Direct
injury to the interstitium and alveoli occurs along the wound track. Hemorrhage within the lung
parenchyma occurs at the time of trauma followed by interstitial edema, which usually begins
within one to two hours and peaks at 24 hours following injury. Such hemorrhage may cause
significant difficulties with oxygenation and ventilation. Occasionally, complications, such as
abscesses or a bronchopleural fistula, can develop following penetrating chest trauma.
● Heart – Penetrating wounds of the heart often cause tamponade physiology or hemorrhagic
shock, depending upon whether blood can escape the pericardial space. Due to the poor
compliance of the pericardium, the acute accumulation of as little as 50 mL of blood can cause
tamponade. The right ventricle is the most commonly injured chamber in penetrating trauma due
to its anterior position within the chest cavity [14,15]. The next most common is the left ventricle.
Atrial injuries are less common and generally less severe, while multi-chamber injuries cause
higher mortality. (See "Cardiac tamponade".)
● Great vessels – Major vessels within the thorax include the aorta, the brachiocephalic trunk, and
the left subclavian, left common carotid, and innominate arteries. Injuries to major vessels are
rarely encountered in the emergency department because most patients with such wounds
expire in the field [16]. However, vascular injury can present as massive hemothorax,
necessitating immediate decompression and emergency operative intervention.
● Tracheobronchial tree – Injuries to the tracheobronchial tree are less common in penetrating
trauma than in blunt trauma and generally involve the cervical trachea [8]. These injuries often go
unrecognized because early symptoms and signs of injury are nonspecific. Although complete
transection of the trachea is usually diagnosed during initial evaluation, partial tears of the
trachea and complete or partial tears of the bronchi may not be detected until the development of
sequelae, such as tracheoesophageal fistula, mediastinitis, or empyema.
● Esophagus – Esophageal injuries can be difficult to detect. The uncommon nature of this injury,
lack of specific clinical signs or chest radiographic findings, and the need for early diagnosis to
avoid dangerous complications necessitate careful evaluation [17]. Further diagnostic testing of
both the esophagus and tracheobronchial tree is needed for any penetrating trauma suspected to
cross the mediastinum. (See "Overview of esophageal perforation due to blunt or penetrating
trauma".)
● Diaphragm – Stab or gunshot wounds to the lower chest often entail injury of the diaphragm.
The diaphragm can rise up to the level of the fourth intercostal space during exhalation and thus
penetrating wounds of the thorax can involve intraabdominal organs as well. (See "Recognition
and management of diaphragmatic injury in adults" and "Initial evaluation and management of
abdominal gunshot wounds in adults" and "Initial evaluation and management of abdominal stab
wounds in adults".)
General concepts about mechanism — The direction and extent of penetration from a stab wound
is difficult to assess from the physical examination, and examination alone has poor sensitivity and
specificity for identifying significant pathology, including pneumothorax and hemothorax [18].
Generally, a knife or other sharp object produces injury along its entry track and may damage any
intrathoracic organ in its path. Although knowledge of the size and shape, as well as the angle and
direction of the entrance, of the wounding instrument provides some guidance about potential injuries,
the extent of internal injury from a seemingly small external wound can easily be underestimated. Of
particular importance are penetrating wounds to “the box” because of the high risk of injury to the
heart and other mediastinal structures [19]. The box is defined superiorly by the clavicles and sternal
notch, laterally by the nipple line, and inferiorly by the costal margins.
Gunshot wounds and other higher velocity implements or debris have a less predictable pattern of
injury. The trajectory of a missile may not follow a straight course. In addition, tissues can sustain
damage not only from the direct path of the bullet, known as the permanent cavity, but also from the
shock waves caused by the bullet, known as the temporary cavity. Temporary cavity wounds are
caused by high velocity missiles. (See "Initial evaluation and management of abdominal gunshot
wounds in adults", section on 'Mechanisms of injury'.)
PREHOSPITAL MANAGEMENT
Any patient with a penetrating chest injury, regardless of apparent stability, should be transported to
the closest facility capable of caring for patients with major injuries. Patients with signs of shock or
respiratory distress should be transported immediately. Scene time should be minimized and
emergency life-saving interventions, such as tracheal intubation or needle decompression of a
tension pneumothorax, are the only activities that may be permitted to delay transport [20].
Intravenous access and fluid resuscitation may be initiated while en route to the hospital [16,21].
Appropriate fluid resuscitation for trauma patients in the prehospital setting is discussed in detail
separately. (See "Prehospital care of the adult trauma patient", section on 'Fluid resuscitation'.)
Patients with certain injuries from penetrating chest trauma may benefit from a select number of
interventions performed in the field [22]. A "sucking" chest wound exists when air enters the pleural
cavity preferentially via an open chest wound, rather than the lungs via the trachea. Placement of an
occlusive dressing, taped on three sides, over a sucking chest wound can seal off air entry into the
pleural cavity and prevent the expansion of a pneumothorax.
Evidence of a tension pneumothorax (eg, severe dyspnea with asymmetric breath sounds and
hypotension) requires prehospital decompression with needle thoracostomy. Decompression appears
to be successful more often when needle thoracostomy is performed in the fourth or fifth intercostal
space using a longer needle (8 cm versus 5 cm) [23,24]. Advanced Trauma Life Support has adopted
this approach in adults and recommends that chest decompression be performed at the fifth
intercostal space in the midaxillary line, rather than the second intercostal space in the midclavicular
line. However, in the prehospital environment, anterior placement may be preferred. Keys to
successful performance of this important procedure are described separately. (See "Prehospital care
of the adult trauma patient", section on 'Needle chest decompression'.)
Whether to maintain spinal precautions in patients suffering from penetrating trauma is a topic of
debate. Isolated, low-energy, penetrating thoracic trauma is unlikely to create spinal instability and
immobilization of the cervical spine may not be necessary in patients who are alert and free of
neurologic deficits [25,26]. However, victims of penetrating trauma may also have sustained blunt
trauma (eg, falling after being shot) and spinal precautions should generally be observed in patients
with alterations in mental status or neurologic deficits. (See "Penetrating neck injuries: Initial
evaluation and management", section on 'Cervical spine immobilization'.)
CLINICAL FINDINGS
Common signs of injury — Clinical findings in patients with penetrating chest trauma vary widely
depending upon the structures injured, the extent of the injuries, concomitant injuries, and the
patient’s body habitus and mental status.
The following symptoms and signs raise suspicion for significant underlying injury in patients who
may not otherwise manifest specific or concerning findings:
● Any vital sign abnormality, especially hypotension, hypoxia, or persistent tachycardia, should
raise suspicion for underlying injury. Young healthy patients or elders in shock may not present in
typical fashion. (See "Initial evaluation of shock in the adult trauma patient and management of
NON-hemorrhagic shock" and "Geriatric trauma: Initial evaluation and management".)
● Persistent shortness of breath (SOB) or pleuritic chest pain suggests injury to the lungs or
pericardium.
● A foreign body sensation in the throat or change in voice suggests tracheal or esophageal injury.
(See "Penetrating neck injuries: Initial evaluation and management".)
● Diminished breath sounds strongly suggest pneumothorax but may not be appreciated if the
pneumothorax is small or the environment is loud.
● Jugular venous distension suggests pericardial effusion. However, jugular veins may appear
prominent in supine patients without an effusion. Conversely, distended veins may not be
present in hypovolemic patients with tamponade.
● Subcutaneous air (crepitus) strongly suggests a tracheobronchial injury or a pneumothorax,

either large or small. Both injuries must be considered.
Specific injuries
Pneumothorax — Pneumothorax should be suspected in any patient with penetrating chest

trauma, although a small pneumothorax may be clinically undetectable. The severity of clinical
findings even in patients with a significant pneumothorax varies and does not necessarily correlate
with size (image 1). Unilateral diminished breath sounds strongly suggest pneumothorax, and
subcutaneous air anywhere in the chest wall of a patient with penetrating thoracic trauma almost
guarantees it. Hyperresonance is more common with tension pneumothorax and may be detectable
with percussion.
Tension pneumothorax causes severe acute respiratory and cardiovascular distress. Symptoms and
signs include dyspnea, agitation, tachycardia, hypotension, depressed mental status, diminished
breath sounds, and in the absence of significant hemorrhage, jugular venous distension. With
intubated patients, airway resistance increases and bag-mask ventilation becomes difficult [27].
Pulmonary contusion — Pulmonary contusion is a direct bruise of the lung, which causes
alveolar hemorrhage and edema [28]. Clinical symptoms and signs of pulmonary contusion include
dyspnea, hypoxia, tachypnea, and hemoptysis. The severity of these signs usually correlates with the
extent of alveolar injury.
Radiographic findings associated with pulmonary contusion most often consist of patchy or diffuse
areas of infiltrate, which may initially be subtle but worsen over 24 to 48 hours, especially in the
setting of large volume fluid resuscitation [29]. Once infiltrates appear, crackles and rhonchi often
become audible and clinical manifestations, such as dyspnea and hypoxia, worsen.
In most cases, significant force (ie, high-energy trauma) is required for a pulmonary contusion. In
addition, high velocity gunshot wounds can cause clinically significant damage to the lung
parenchyma.
Hemothorax — Patients with injuries to the great vessels rarely survive to reach the hospital.
Survivors with a significant hemothorax have often sustained injuries to the lung parenchyma, or
possibly intercostal blood vessels. Depending upon the size of the hemothorax, breath sounds are
diminished and signs of shock may be present. Hemothorax often occurs concomitantly with
pneumothorax and other injuries.
Pericardial tamponade — Any patient with a penetrating wound to the chest, back, neck, or
abdomen can develop pericardial tamponade. If the rate of bleeding is slow or the pericardium
periodically decompresses by emptying blood into the pleural space, patients may initially appear
stable [27]. Some patients may complain of shortness of breath. Beck’s triad (hypotension, jugular
venous distension (JVD), muffled heart sounds) can be difficult to detect and may not be present. In
hypovolemic patients, JVD may be absent. Ultimately, tamponade physiology causes diminished
cardiac output, leading to a decrease in systolic blood pressure and a narrowing of the pulse
pressure. Diagnosis should be determined rapidly by ultrasound, if immediately available (waveform 1
and movie 1 and movie 2). (See 'Extended Focused Assessment with Sonography in Trauma' below
and "Emergency ultrasound in adults with abdominal and thoracic trauma", section on 'Pericardial and
limited cardiac examination'.)
Tracheobronchial injury — Lacerations of the trachea or bronchi allow air into the mediastinum,
which can dissect into the soft tissues of the anterior neck (image 2 and image 3). This subcutaneous
emphysema may be palpable. A crunching sound (Hamman’s sign) may be heard over the
precordium, reflecting the presence of air in the mediastinum. Air may leak into the pleural space
leading to symptoms and signs of a pneumothorax. Neck injuries involving the tracheobronchial tree
and the esophagus are discussed separately. (See "Penetrating neck injuries: Initial evaluation and
management".)
Esophageal injury — Esophageal injuries have no specific associated clinical signs and are
notoriously difficult to diagnose, but patient mortality increases substantially when diagnosis is
delayed [17]. Symptoms and signs may include painful swallowing, throat, neck, or chest pain, cough,
hematemesis, difficulty breathing, and subcutaneous emphysema. Any patient with possible
esophageal injury must be evaluated with advanced diagnostic imaging. (See 'Secondary survey'
below and 'Chest computed tomography (CT)' below and 'Esophagoscopy and esophagography'
below.)
INITIAL EVALUATION AND MANAGEMENT
Before beginning the primary survey, the patient’s appearance may provide the clinician with a clear
sense of their condition. Respiratory distress, diaphoresis, combativeness, or an unwillingness to lie
flat may signal active or imminent cardiopulmonary decompensation.
Rapid assessment of the patient with penetrating chest trauma is essential. The primary survey of
Advanced Trauma Life Support provides a clear approach to the initial evaluation of the trauma
patient organized according to the injuries that pose the most immediate threats to life. Many such
injuries involve thoracic structures.
The primary survey is reviewed in detail separately; aspects of the survey of particular importance to
penetrating thoracic trauma are discussed below. (See "Initial management of trauma in adults",
section on 'Primary evaluation and management'.)
Airway — Assessment of the airway to determine its patency and the need for tracheal intubation is
generally the first step of the primary survey [30]. However, immediate tracheal intubation of patients
with pericardial tamponade or a tension pneumothorax can exacerbate hypotension and even cause
cardiovascular collapse. This is due to the increased intrathoracic pressure caused by positive
pressure ventilation, which reduces venous return. Therefore, whenever possible, evacuation of the
pericardial effusion or decompression of the pneumothorax should be performed first, while the
patient is prepared for intubation.
If time allows and resources are available, it is best to perform these procedures (including tracheal
intubation) in the operating room, but this may not be possible in unstable patients. In addition,
management will vary depending upon clinical circumstances. As examples, a patient with an isolated
tension pneumothorax treated successfully with a chest tube may not need to go to the operating
room while a patient with tamponade physiology will require surgical repair (eg, thoracotomy or
pericardial window).
Airway management is discussed in detail separately. (See "Basic airway management in adults" and
"Advanced emergency airway management in adults" and "Rapid sequence intubation for adults
outside the operating room".)
Breathing — Breathing assessment in penetrating chest trauma includes inspection of the chest wall
for asymmetries in appearance or chest rise, auscultation of breath sounds, palpation of the chest
wall for flail segments, step-off, and crepitus, and palpation of the trachea for any deviation from
midline. In patients with a tension pneumothorax, asymmetric breath sounds, hypoxia, and
hypotension are common; tracheal deviation is a late finding. Oxygenation is measured with a pulse
oximeter and oxygen provided as necessary.
Although the sensitivity of physical examination for a large pneumothorax appears to be better,
physical examination has not been shown to be sufficiently sensitive to rule out a pneumothorax or
hemothorax from penetrating trauma [18,31,32].
If the clinician detects asymmetric breath sounds and the patient is hemodynamically unstable or
shows signs of respiratory distress, a tension pneumothorax is assumed to be present and a
thoracostomy (chest) tube is inserted immediately [30]. Needle decompression may be performed
first if there is any delay in placing the chest tube.
A 28 to 32 French chest tube should be used for thoracostomy in the setting of penetrating trauma
[33,34]. Available evidence for the use of small-bore catheters (eg, 14 French) to manage traumatic
hemothoraces is of limited quality, and further research is required before changes to standard
practice can be considered [35,36]. If few experienced trauma clinicians are present, the chest tube is
placed prior to assessing the circulation; at trauma centers with multiple clinicians available,
assessment and management of the airway, breathing, and circulation are often performed in parallel,
under the direction of the team leader. (See "Initial management of trauma in adults", section on
'Trauma team' and "Placement and management of thoracostomy tubes and catheters in adults and
children" and "Prehospital care of the adult trauma patient", section on 'Needle chest
decompression'.)
Circulation — Check for diminished pulses and hypotension. Look for tension pneumothorax and
cardiac tamponade in any patient with hypotension following penetrating thoracic trauma.
The best to approach to volume resuscitation in patients with isolated penetrating thoracic trauma
remains uncertain. For patients with signs of hemorrhagic shock, fluid resuscitation with either
isotonic saline or lactated ringers and transfusion with blood products is administered as necessary.
Blood products should be given as soon as the need for transfusion is recognized. Diagnosis and
treatment of shock in the adult trauma patient is discussed in detail separately. (See "Initial evaluation
of shock in the adult trauma patient and management of NON-hemorrhagic shock" and "Initial
management of moderate to severe hemorrhage in the adult trauma patient".)
Low-volume resuscitation (or "permissive hypotension"), as part of a "damage-control resuscitation"

approach to the critical trauma patient may offer a survival benefit over conventional resuscitation
strategies for patients with significant hemorrhage from penetrating trauma. Low-volume resuscitation
aims to use the minimum volume of fluid necessary to maintain organ perfusion and tissue
oxygenation while preventing the dilution of clotting factors, hypothermia, and disruption of thrombus
from excessive IV fluid. Young, otherwise healthy trauma patients with penetrating torso injuries and
no evidence of head injury, being treated surgically at a major trauma center, are likely the best
candidates for this approach. However, much remains uncertain about low-volume resuscitation and
further research is needed. This approach is reviewed in greater detail separately. (See "Initial
management of moderate to severe hemorrhage in the adult trauma patient", section on 'Delayed
fluid resuscitation/controlled hypotension' and "Overview of damage control surgery and resuscitation
in patients sustaining severe injury".)
Extended Focused Assessment with Sonography in Trauma — The Extended Focused

Assessment with Sonography in Trauma (E-FAST) examination is an important part of the initial
evaluation of patients with penetrating chest trauma. It accurately detects the presence of
hemopericardium, pneumothorax, hemothorax, and peritoneal fluid, thereby helping to determine
management priorities. A detailed description of how to perform E-FAST, and the clinical evidence
supporting its use in penetrating thoracic trauma, are presented separately. (See "Emergency
ultrasound in adults with abdominal and thoracic trauma".)
The pericardial ultrasound examination is performed first and identifies hemopericardium with high
sensitivity, specificity and accuracy. However, there are case reports of false-negative examinations.
These inaccurate examinations occur most commonly in patients with concurrent, large
hemothoraces or mediastinal hemorrhage. To improve accuracy in such cases, we recommend that
the pericardial ultrasound examination be repeated after the hemothorax is cleared by chest tube.
False-negative examinations remain possible despite such maneuvers if the hemopericardium
empties into the thoracic cavity, thereby preventing blood from accumulating in the pericardium. (See
"Emergency ultrasound in adults with abdominal and thoracic trauma", section on 'Pericardial and
limited cardiac examination'.)
An abdominal ultrasound examination showing intraperitoneal free fluid following thoracoabdominal

trauma strongly suggests an intraabdominal injury, and in hemodynamically unstable patients assists
in rapidly prioritizing operative interventions. (See "Emergency ultrasound in adults with abdominal
and thoracic trauma", section on 'Abdominal examination'.)
Of note, in penetrating trauma, a negative E-FAST does not definitively exclude intra-abdominal
wounds, such as a diaphragm or hollow viscous injury, and further evaluation with serial abdominal
examinations, diagnostic peritoneal tap and lavage, computed tomography (CT), or exploratory
surgery is required [37].
Thoracoabdominal trauma — Thoracoabdominal wounds present a diagnostic challenge as

movement of the diaphragm makes it difficult to predict the tract of a penetrating injury [38]. If the
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wound is close to the upper abdomen, intraabdominal and diaphragmatic injuries must be considered
and evaluated in addition to intrathoracic injury. Clinicians should consider the possibility of
diaphragmatic and intra-abdominal injuries with all anterior penetrating wounds that lie inferior to the
nipple line (fourth intercostal space) and posterior penetrating wounds inferior to the tip of the scapula
(seventh intercostal space). Potential sites of intraabdominal injury include the liver, spleen, aorta and
other great vessels. Diaphragmatic injury is often impossible to rule out solely on the basis of the
physical examination. (See "Initial evaluation and management of abdominal stab wounds in adults"
and "Initial evaluation and management of abdominal gunshot wounds in adults" and "Recognition
and management of diaphragmatic injury in adults".)
Triage and transfer to a trauma center — Patients with symptoms or signs of significant injury
following penetrating thoracic trauma should be transported directly to a trauma center whenever
possible, rather than a community hospital. Retrospective studies suggest that mortality is reduced
when severely injured patients are transported directly to a trauma center [39-43], and direct transport
may be of relatively greater importance with penetrating thoracoabdominal injuries. However, field
triage and transfer decisions may not be straightforward in some instances and the responsible
clinician may need to consider such factors as the severity of injuries, local resources, and
(particularly in rural areas) the distance and time necessary to complete the transfer to a trauma
center [44,45].
Some patients with penetrating thoracic trauma will receive their initial care at community hospitals,
possibly because they are initially asymptomatic. Indications for transfer to a higher level of care
depend upon the needs of the patient and the capabilities of the clinicians and hospital [46]. In all
cases, once the clinician determines that a trauma patient requires a higher level of care, transfer
should be arranged as quickly as possible and should not be delayed for further diagnostic
evaluations. Arranging transfer is sometimes difficult but rapid transport to a tertiary care hospital can
be life-saving and must be anticipated.
The primary survey and initial interventions for life-threatening injuries of patients with penetrating
chest trauma is no different at the community hospital, with the possible exception of emergency
department (ED) thoracotomy. ED thoracotomy is not recommended if surgical back-up is not readily
available. Appropriate airway management and resuscitation remain cornerstones of care. Patients
meeting criteria for tube thoracostomy should have chest tubes placed prior to transfer and chest
radiographs performed to confirm proper placement. Patients with ultrasound evidence of
hemopericardium may benefit from pericardiocentesis and placement of a catheter that can be used
to decompress the pericardium in case signs of tamponade develop during transport. (See
'Emergency department thoracotomy (EDT)' below and "Emergency pericardiocentesis".)
SECONDARY SURVEY
Definitive management of a hemodynamically unstable patient with penetrating thoracic trauma must
not be delayed to perform a more detailed secondary evaluation. Such patients are taken directly to
the operating room or angiography suite, or transferred to a major trauma center.
A careful, head-to-toe secondary assessment (ie, secondary survey) is performed in all trauma
patients determined to be stable upon completion of the primary survey. The secondary survey is
discussed in detail separately. (See "Initial management of trauma in adults", section on 'Secondary
evaluation'.)
In patients with penetrating thoracic trauma, the clinician asks about symptoms, such as dyspnea,
odynophagia, chest pain, and back pain, which may reflect a worsening pneumothorax, esophageal
perforation, or tracheobronchial injury. Physical examination findings consistent with these injuries
can include hematemesis, stridor, chest wall crepitus, and a crunching sound (Hamman’s sign) heard
over the precordium, suggesting air in the mediastinum. Symptoms and signs of esophageal injury
are nonspecific but may include chest pain, followed by fever, dyspnea, and chest wall crepitus.
Chest wounds should be carefully examined for hematomas and air bubbling through the opening.
Care of the thoracic trauma patient does not end with the secondary survey. Continual reassessment
of the primary survey and areas of potential injury is essential. Patients with penetrating thoracic
trauma can deteriorate rapidly, and neither stable vital signs nor the absence of symptoms initially
excludes the presence of a life-threatening injury. Continuous pulse oximetry monitoring is needed for
patients with evidence of pulmonary injury, such as contusion or pneumothorax. In addition, if
suspicion of pneumothorax or hemopericardium persists or increases, repeat bedside
ultrasonography should be performed.
DIAGNOSTIC IMAGING
Chest radiograph — In general, a plain chest radiograph is obtained for all hemodynamically stable
patients who present with penetrating chest trauma, whether or not they are experiencing signs or
symptoms of intrathoracic injury. For stable patients, many recommend obtaining a posteroanterior
(PA) film with the patient upright. With more severely injured patients, this approach is often
impractical and possibly dangerous if spinal injuries are suspected. Supine anteroposterior (AP) films
are generally obtained in such cases. Retrospective studies suggest that chest radiographs taken
during expiration do not increase the sensitivity for detecting pneumothorax [47,48].
Up to 62 percent of civilian patients who are admitted with penetrating injuries to the chest are
asymptomatic and have normal chest radiographs [49]. However, the initial chest radiograph shows
variable sensitivity in detecting injuries, such as pneumothorax and hemothorax. Some studies report
sensitivities for the detection of pneumothorax as low as 36 to 48 percent for supine AP films (image
1 and image 4) [50-52].
Injuries may not manifest initially. Early studies showed that 2 to 12 percent of initially asymptomatic
patients with a normal AP chest radiograph at presentation are at risk for subsequently developing a
pneumothorax or hemothorax. However, the negative predictive value of plain radiographs to
diagnose these injuries increases to nearly 100 percent if repeated six hours after presentation [53].
Several small subsequent studies have found that a normal repeat upright PA chest radiograph
performed at three hours is likely as sensitive as a repeat chest radiograph done at six hours [54-56].
Other important injuries may be detected on AP chest radiograph. Radiographic findings of

pulmonary contusion range from patchy, irregular, alveolar infiltrates to frank consolidation. Usually
these changes are present on the initial examination, but may worsen over the next several hours
[28]. Cervical and mediastinal emphysema, alteration of the mediastinal contour, and left pleural
effusion may be signs of esophageal injury. Rib fractures may also be identified. While not well
studied, the straight left heart border sign (filling in of the left heart border inferior to the pulmonary
artery) suggests the presence of hemopericardium after penetrating chest injury. In a study of 162
patients with penetrating chest trauma treated with a pericardial window, the sensitivity of this sign
was 40 percent and the specificity 84 percent [57].
Thoracic ultrasound — We recommend that an ultrasound examination of the chest (E-FAST) be

performed in all patients with penetrating chest trauma who do not proceed immediately to the
operating room upon arrival. Ultrasound is easily portable, immediately available, and non-invasive.
Overall, ultrasound appears to have superior sensitivity and similar specificity to supine AP chest
radiography for the identification of pneumothorax in adults. Of note, the size and location of a
pneumothorax affects ultrasound’s accuracy (as is the case with plain radiographs); small apical and
medial pneumothoraces are more difficult to detect.
Detection of pneumothorax is based on the absence of pleural sliding and comet tail artifacts. The
presence of pleural sliding excludes the diagnosis of pneumothorax at that location on the chest wall.
Performance of the ultrasound examination in the setting of thoracic trauma and the ultrasound
findings associated with the presence of a pneumothorax are discussed in greater detail separately.
(See "Emergency ultrasound in adults with abdominal and thoracic trauma", section on 'Pleural
examination'.)
Echocardiography — When the heart can be clearly visualized (eg, hemothorax does not obscure
the image), the sensitivity of the cardiac portion of the FAST examination for identifying
hemopericardium after penetrating chest trauma is reported to be as high as 100 percent [58,59],
decreasing the need to obtain formal echocardiography. However, if the FAST examination cannot be
performed or is inadequate because the heart cannot be well visualized or findings are ambiguous,
formal transthoracic echocardiography should be performed if there is any concern for cardiac injury.
Chest computed tomography (CT) — Indications for obtaining a chest CT in a hemodynamically

stable patient with penetrating thoracic trauma include the following:
● Trajectory of a penetrating object crosses the mediastinum or middle of the chest.
● Symptoms or signs concerning for esophageal or tracheobronchial or vascular injury are present.
(See 'Clinical findings' above.)
● Chest pain, shortness of breath, or other symptoms consistent with injury are present that are not
explained adequately by a plain chest radiograph.
These indications are not exhaustive and if there is clinical suspicion for a thoracic injury on other
grounds it is reasonable to obtain a CT. CT of the chest demonstrates the greatest sensitivity and
specificity for detecting pneumothorax and hemothorax, and most studies of ultrasound and chest
radiographs use CT as the gold standard. However, CT exposes the patient to higher levels of
radiation and may not be necessary if initial and follow-up plain chest radiographs are normal and
there is no clinical suspicion for aortic or other major thoracic injury.
Overcrowded emergency departments are common, causing some patients to leave before repeat
chest radiographs are obtained. Thus, some centers choose to perform an initial chest CT rather than
plain chest radiographs to rule out pneumothorax and hemothorax, thereby ensuring the absence of
gross injury and expediting disposition [60]. However, in the young, low-risk patient, this approach
may be harder to justify when both cost and radiation risks are considered.
Any patient with a knife or gunshot wound that traverses the mediastinum should be evaluated with a
chest CT. Injuries to a number of vital structures, including the heart, great vessels, esophagus, and
trachea, can be missed on plain chest radiograph [61-63]. If CT reveals that the wound track does not
traverse the mediastinum or travel close to vital structures, additional diagnostic imaging, such as
angiography, echocardiography, and esophagoscopy, may be unnecessary [61,62].
Direct visualization of the tracheobronchial tree with bronchoscopy and evaluation of the esophagus
with either esophagoscopy or a contrast esophagogram is necessary for any trajectory that passes
close to mediastinal structures. Esophageal injuries in particular have a high incidence of morbidity
and mortality when surgical repair is delayed, making early diagnosis imperative. (See
'Bronchoscopy' below and 'Esophagoscopy and esophagography' below.)
Some experts claim that a single non-contrast chest CT is preferable to serial chest radiographs in
penetrating thoracic trauma for the exclusion of pneumothorax or other thoracic injury requiring
intervention [64]. A normal non-contrast chest CT allows for expedited discharge, relieving
overcrowded emergency departments, and may reduce costs [60]. According to a ten-year
retrospective review from a single, level one trauma center, CT detected injuries not identified by plain
chest radiograph in up to one-third of patients, but of the 42 patients found with such injuries, only 16
required significant intervention (tube thoracostomy in 14 and surgery for hemopericardium in 2) [65].
While CT is not the screening test of choice for pericardial effusions, especially in a symptomatic
patient, one retrospective study reported that CT detected all four effusions present among the 60
patients with penetrating chest trauma who were evaluated [66].
CT is useful for excluding intraabdominal injury in hemodynamically stable patients with

thoracoabdominal wounds. The trajectory of many penetrating injuries is difficult to assess by
examination, and evaluation of the diaphragm, stomach, intestines, and solid organs using abdominal
CT is often necessary. In a small study of hemodynamically stable patients, clinicians inserted sterile
sponges soaked with Betadine or Visipaque into the tracts of posterior or flank stab wounds to
improve wound visualization on CT [67]. Although effective in this small sample, further study of this
technique is needed.
Multidetector CT (MDCT) is a useful method for evaluating the diaphragm in patients with penetrating
trauma, provided the entire contour of the diaphragm is visualized and not obscured by artifact,
effusion, or bone fragments. If high quality images obtained with a MDCT suggest the presence of
diaphragmatic injury, further evaluation is warranted. (See "Recognition and management of
diaphragmatic injury in adults", section on 'Computed tomography'.)
Preliminary retrospective studies suggest that CT esophagography is sensitive and specific for
identifying penetrating esophageal and hypopharyngeal injuries [68]. However, given the limitations of
these small studies and morbidity and mortality associated with missed esophageal injury,
confirmation of such injuries with esophagography remains the preferred approach at many trauma
centers.
Esophagoscopy and esophagography — An esophagram is usually performed in any patient with

transmediastinal injuries or possible injury of the esophagus. Some centers perform a contrast
esophagram with water-soluble contrast first and, if that study is negative, then repeat the study using
barium sulfate contrast [69]. Other centers recommend a single contrast esophagram with barium
rather than water-soluble contrast for increased sensitivity, superior image quality, and decreased risk
of aspiration [70,71]. Flexible esophagogastroduodenoscopy (EGD) is an alternative approach but is

generally less favored in the acute trauma setting because of the risk of causing additional injury,
including pneumothorax. Whichever approach is used, rapid diagnostic evaluation is important
because morbidity is reduced and the best surgical results are obtained when the time between injury
and repair is minimized [72].
Bronchoscopy — Bronchoscopy is the diagnostic modality of choice to confirm injuries to the

tracheobronchial tree. Early diagnosis is essential to reduce morbidity and obtain a successful
primary reanastomosis [73].
DISPOSITION AND DEFINITIVE MANAGEMENT
Asymptomatic patient — Asymptomatic patients with penetrating thoracic injuries and a normal
chest radiograph and eFAST ultrasound examination at presentation are observed for development of
a delayed pneumothorax or hemothorax. A repeat examination and chest radiograph should be
performed six hours after arrival. If the reevaluation is unremarkable, the patient can be discharged
from the emergency department (ED), with instructions to return immediately should any concerning
symptoms (eg, increasing shortness of breath, painful swallowing) develop.
While this is not our approach, some centers shorten the observation time and repeat the chest
radiograph at three hours post injury based upon the results of small retrospective studies [54-56],
while others perform initial noncontrast chest computed tomography (CT) to expedite patient
disposition [60].
Patient with isolated pneumothorax or hemothorax — Pneumothorax is the most common serious
injury associated with penetrating thoracic trauma and tube thoracostomy (ie, chest tube) is the most
common intervention needed for treatment [74]. A chest tube alone is sufficient to manage 85 percent
of cases.
Tube thoracostomy is needed for any patient with a pneumothorax who has chest pain, dyspnea, or
hypoxia. Among asymptomatic patients, a chest tube is needed for any pneumothorax that occupies
over 15 percent of the lung’s total volume, as these are not likely to resolve spontaneously.
Hemothoraces of volumes greater than 300 to 500 mL are treated with tube thoracostomy (28 to 32
French chest tube). A volume of 300 mL is needed for hemothorax to manifest on an upright chest
radiograph. Large hemothoraces that remain undrained can compromise ventilation and may not
resorb, and this unresorbed blood can eventually lead to infection and pulmonary fibrosis.
Immediate bloody drainage of ≥20 mL/kg (approximately 1500 mL) is generally considered an
indication for surgical thoracotomy. Shock and persistent, substantial bleeding (generally >3
mL/kg/hour) are additional indications. Vital signs, fluid resuscitation requirements, and concomitant
injuries are considered when determining the need for thoracotomy.
Occult pneumothorax — The management of occult pneumothorax, defined as a pneumothorax

observed on CT but not visible on a plain chest radiograph, is discussed separately. (See "Initial
evaluation and management of blunt thoracic trauma in adults", section on 'Occult pneumothorax'.)
Indications for operative management — Approximately 15 percent of patients with penetrating

thoracic trauma require surgical management. Indications for urgent thoracotomy include cardiac
tamponade and significant hemorrhage or a persistent air leak from a chest tube.
The presence of cardiac tamponade, most often identified by ultrasound during the FAST
examination, mandates intervention with a pericardial window or median sternotomy. For
hemodynamically unstable patients, emergency pericardiocentesis and placement of a catheter may
be needed (see "Emergency pericardiocentesis"). However, pericardiocentesis cannot be relied upon
for definitive diagnosis and provides only temporary pericardial decompression when a thoracotomy
cannot be performed promptly. However, pericardial drainage in the emergency department is a
reasonable option when surgery is not immediately available and the patient is hypotensive or
otherwise appears hemodynamically unstable.
The drainage of massive amounts of blood upon placement of a chest tube indicates the presence of
a major vascular injury that is unlikely to stop without surgical intervention. Many authors use 1500
mL of immediate chest tube drainage as the threshold for surgical thoracotomy, but others use 1000
mL [75]. Some authorities use 20 mL/kg as the surgical threshold. Ongoing bleeding at a rate of 200
to 300 mL/hour is another common indication for chest exploration [76,77].
Massive air leak is an indication for surgical exploration of the chest after penetrating injury. Massive
air leak is defined as one present during all phases of respiration and preventing full expansion of the
affected lung or impairing ventilation through diminished tidal volume [75]. These findings suggest
major tracheobronchial injury that is unlikely to heal without surgical repair.
EMERGENCY DEPARTMENT THORACOTOMY (EDT)
Overview and survival — Emergency thoracotomy is performed to resuscitate trauma patients who
have just sustained or are on the verge of cardiac arrest. A left anterolateral thoracotomy enables
knowledgeable clinicians to perform several potentially life-saving maneuvers, including
pericardotomy to decompress pericardial tamponade, temporary repair of penetrating myocardial
wounds, cross-clamping of the descending thoracic aorta (thereby preventing exsanguinating
hemorrhage in the abdomen and increasing perfusion of the brain and heart), and open cardiac
massage. The performance of EDT is discussed separately. (See "Resuscitative thoracotomy:

Technique".)
The effectiveness of EDT varies widely depending upon the location and mechanism of injury and
whether signs of life were present upon arrival at the hospital [78-81]. According to multiple
systematic reviews involving many thousands of cases of EDT performed at multiple institutions over
approximately 30 years, survival following EDT is greatest among patients with isolated stab wounds
to the heart who show signs of life at presentation [78,79,82]. Conversely, survival is rare among blunt
trauma victims without signs of life upon arrival or patients with multiple gunshot wounds to the chest
[83-85].
When analyzed by recognized factors of clinical importance, survival rates following EDT are as
follows [78]:
● Mechanism of injury:
• Stab wound – 16.8 percent
• Gunshot wound – 4.3 percent
• Blunt trauma – 1.4 percent
● Location of injury:
• Thoracic injuries – 10.7 percent
• Abdominal injuries – 4.5 percent
• Multiple injuries – 0.7 percent
● Signs of life:
• Signs of life in the hospital – 11.5 percent
• Signs of life during transport – 8.9 percent
but not in the hospital
• No signs of life in the field – 1.2 percent
Survival data from a subsequent review performed by the Eastern Association for the Surgery of
Trauma (EAST), including neurologically-intact survival, is summarized in the accompanying table
(table 1).
Indications — EDT entails risk [86]. Transmission of communicable diseases, such as HIV and
hepatitis, can occur; multiple sharp instruments, suture needles, and open rib fractures can cause
iatrogenic injury. In addition, patients receiving EDT require many resources, diverting care from other
patients in frequently over-burdened trauma centers. Given the resources required and risks entailed
in EDT, we strongly recommend that hospitals develop policies to determine the circumstances under
which the procedure is to be performed.
We believe that EDT is justified if the following conditions are met:
● Patient manifests signs of life in the field or the hospital, AND
● Patient has penetrating thoracic trauma and is hemodynamically unstable despite appropriate
fluid resuscitation OR has not been pulseless for longer than 15 minutes, AND
● A thoracic or trauma surgeon is available within approximately 45 minutes
Signs of life that justify the performance of EDT include: spontaneous breathing, palpable carotid
pulse, measurable blood pressure, electrical cardiac activity, pupillary response to light, and
spontaneous extremity movement [79,87].
We believe that EDT is futile in the following circumstances:
● Patient has no pulse or blood pressure in the field
● Asystole is the presenting rhythm, and there is no pericardial tamponade
● Prolonged pulselessness (over 15 minutes) occurs at any time
● Massive, nonsurvivable injuries have occurred
● No thoracic or trauma surgeon is available within approximately 45 minutes
This approach is largely consistent with major society practice guidelines, which are described below
[79,80,82]. In addition, we agree with the general warning expressed in guidelines from the Western
Trauma Association that hospital-based physicians must be cautious about prematurely abandoning
resuscitation efforts based upon prehospital assessment [80]. Ultrasound is a useful tool for helping
to determine when the risks and resource burdens of EDT may be justified by helping to identify likely
survivors [88].
The time frame in which a surgeon should be available following EDT is an approximation and not
based upon any clear evidence or published guidelines. Given the logistics of community emergency
medicine practice, 45 minutes seems to be a reasonable period. However, the appropriate time frame
varies depending upon physician judgement and clinical circumstances. As examples, a longer period
might be appropriate in the case of an isolated stab wound to the right atrium where bleeding is
rapidly controlled and blood pressure maintained or when abdominal bleeding is well controlled by
cross-clamping of the aorta and intermittent release of the clamp every 10 to 30 minutes is performed
to reduce the risk of spinal cord ischemia and permanent injury while awaiting the surgeon's arrival.
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is being investigated as a

possible alternative to EDT in some trauma patients, possibly including blunt thoracic trauma. (See
"Endovascular methods for aortic control in trauma".)
Guidelines from trauma organizations — The appropriate indications for emergency resuscitative
thoracotomy continue to be debated in the literature, and several practice guidelines have been
published, including ones from the American College of Surgeons Committee on Trauma (ACS-COT),
the Western Trauma Association (WTA), and the Eastern Association for the Surgery of Trauma
(EAST), which are summarized below.
Practice Management Guidelines published by the American College of Surgeons Committee on

Trauma (ACS-COT) include the following recommendations [79]:
● EDT is best applied to patients sustaining penetrating cardiac injuries who arrive at trauma
centers after a short scene and transport time with witnessed or objectively measured
physiologic parameters showing signs of life.
● EDT should be performed in patients sustaining penetrating noncardiac thoracic injuries, but
these patients generally experience a low survival rate. Because it is difficult to ascertain whether
the injuries are noncardiac thoracic versus cardiac, EDT can be used to establish the diagnosis.
● EDT should be performed rarely in the patient sustaining cardiopulmonary arrest secondary to
blunt trauma because of its very low survival rate and poor neurologic outcomes. It should be
limited to patients who arrive with vital signs at the trauma center and experience witnessed
cardiac arrest.
● EDT should be performed in patients sustaining exsanguinating abdominal vascular injuries, but
these patients generally experience a low survival rate.
Practice Management Guidelines published by the Western Trauma Association include the following
recommendations for EDT, referred to as Resuscitative Thoracotomy (RT) in these guidelines [80]:
● Patients undergoing cardiopulmonary resuscitation (CPR) on arrival to the hospital should be

stratified based on injury and transport time.
● Indications for RT include the following:
• Blunt trauma patients with less than 10 minutes of prehospital CPR

• Penetrating torso trauma patients with less than 15 minutes of CPR
• Patients with penetrating trauma to the neck or extremity with less than 5 minutes of
prehospital CPR
• Patients in profound refractory shock.
● Immediately following RT, the patient's intrinsic cardiac activity is evaluated; patients in asystole
without cardiac tamponade are declared dead.
The Eastern Association for the Surgery of Trauma attempted to use the GRADE methodology to
formulate recommendations for the appropriate use of EDT, including the following [82]:
● A strong recommendation that patients who present pulseless with signs of life after penetrating
thoracic injury undergo EDT.
● A conditional recommendation for EDT in patients who present pulseless and have absent signs
of life after penetrating thoracic injury, present or absent signs of life after penetrating extra-
thoracic injury, or present signs of life after blunt injury.
● A conditional recommendation against EDT for pulseless patients without sign of life after blunt
injury.
OUTCOMES
Overall mortality for severe penetrating thoracic trauma is high. However, among patients who survive
to hospital admission, mortality is approximately 5 to 6 percent [89]. Outcomes correlate with the
extent of injury and timeliness of treatment. Patients who are hemodynamically stable at presentation
generally recover well with appropriate management.
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions around
the world are provided separately. (See "Society guideline links: General issues of trauma
management in adults" and "Society guideline links: Thoracic trauma".)
SUMMARY AND RECOMMENDATIONS
● The presentation of penetrating thoracic trauma can vary widely, from stable patients with few
complaints to hemodynamically unstable patients requiring immediate life-saving interventions.
The thoracic structures at risk from penetrating chest trauma include the chest wall (including
intercostal neurovascular bundles), lungs, tracheobronchial tree, heart, aorta and thoracic great
vessels, esophagus, diaphragm, spinal cord, thoracic vertebrae, and the thoracic duct. (See
'Anatomy, pathophysiology, and mechanism' above.)
● Clinical findings in patients with penetrating chest trauma vary widely depending upon the
structures injured, the extent of the injuries, concomitant injuries, and the patient’s body habitus
and mental status. Symptoms and signs consistent with significant underlying injury include
abnormal vital signs, persistent dyspnea, pleuritic chest pain, foreign body sensation in the throat
or change in voice, diminished breath sounds, jugular venous distension, and subcutaneous air.
Clinical findings associated with common injuries are described in the text. (See 'Clinical findings'
above.)
● Rapid assessment of the patient with penetrating chest trauma is essential. The primary survey
of the adult trauma patient is reviewed in detail separately; aspects of the survey of particular
importance to penetrating thoracic trauma are discussed in the text. (See "Initial management of
trauma in adults", section on 'Primary evaluation and management' and 'Initial evaluation and
management' above.)
● Immediate tracheal intubation of patients with pericardial tamponade or a tension pneumothorax

can exacerbate hypotension and even cause cardiovascular collapse. Therefore, whenever
possible, evacuation of the pericardial effusion or decompression of the pneumothorax should be
performed first, while the patient is prepared for intubation. (See 'Airway' above.)
● The best approach to volume resuscitation in patients with isolated penetrating thoracic trauma
remains uncertain. Blood products should be given as soon as the need for transfusion is
recognized. Low-volume resuscitation or permissive hypotension may offer a survival benefit.
(See "Initial management of moderate to severe hemorrhage in the adult trauma patient".)
● Imaging studies used to evaluate patients with penetrating thoracic trauma are reviewed in the
text. Ultrasound (E-FAST examination) and plain chest radiography are performed in nearly all
cases that do not require immediate transfer to the operating room. A chest CT is performed if
there is concern for esophageal, tracheobronchial, or vascular injury. (See 'Diagnostic imaging'
above.)
● Patients with penetrating chest trauma who have just sustained or are on the verge of cardiac
arrest in the emergency department may benefit from emergency thoracotomy. The indications,
contraindications, and utility of emergency thoracotomy are reviewed in the text. (See
'Emergency department thoracotomy (EDT)' above.)
● Continual reassessment of the primary survey and areas of potential injury is essential. Patients
with penetrating thoracic trauma can deteriorate rapidly, and neither stable vital signs nor the
absence of symptoms initially exclude the presence of a life-threatening injury. (See 'Disposition
and definitive management' above and 'Outcomes' above.)
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Topic 13862 Version 28.0
GRAPHICS
Pneumothorax
This posterior-anterior (PA) radiograph of the chest reveals a left pneumothorax.

The lateral border of the lung (arrows) no longer lies adjacent to the chest wall and
the lung parynchema is contracted accounting for the lung's abnormal appearance.
Note the air and absence of lung markings along the left lateral border of the heart
(small arrowheads) and the inferior and medial displacement of the left mainstem
bronchus. The border of the scapula (large arrowheads) is sometimes mistaken for
a pneumothorax.
Graphic 53428 Version 3.0
Intracardiac hemodynamic tracings showing acute cardiac

tamponade
The radial arterial tracing shows tachycardia and extreme pulsus paradoxus. The right
atrial and pericardial pressures are equally elevated, but the amount of effusion was
very small. Note deeper y descent in the pericardial pressure compared with the right
atrial pressure. ECG shows low voltage. Heavy time markings = 1 second.
Reproduced with permission from: The Pericardium, 2nd ed, Shabetai R (Ed), Kluwer
Academic Publishers, Norwell MS 2003. Copyright © 2003 Kluwer Academic Publishers.
Chest radiograph showing pneumomediastinum
These AP and lateral views of the chest demonstrate pneumomediastinum (inferior arrows) with air
tracking up into the soft tissues of the neck (superior arrows) in a patient with a tracheobronchial injury.
AP: anterior-posterior.
Courtesy of Pierre J Sasson, MD.
CT scan of pneumomediastinum
This axial CT of the chest with lung windows demonstrates extensive

pneuomediastinum (arrow) in the patient whose plain radiographs appear in the
accompanying graphic.
CT: computed tomography.
Courtesy of Pierre J Sasson, MD.
Chest x-ray with apical pneumothorax
The film demonstrates a small left apical spontaneous pneumothorax. The

visceral pleural line is marked by the red arrows.
Analysis of trauma patient survival following emergency department thoracotomy
Number of Hospital % (95%

studies survival CI)
Injury mechanism
Penetrating injury 64 674/6390 10.6 (9.8-11.3)
Percentage of surviving penetrating trauma patients 35 282/312 90.4 (86.7-

neurologically intact post-EDT 93.3)
Gun shot wounds 44 213/2966 7.2 (6.3-8.2)
Stab wounds 44 302/1907 15.8 (14.3-

17.5)
Blunt injury 42 50/2172 2.3 (1.7-3.0)
Percentage of surviving blunt trauma patients 8 19/32 59.4 (41.9-

neurologically intact post-EDT 75.2)
Primary injury location
Cardiac 24 250/1449 17.3 (15.4-

19.3)
Thoracic 27 222/2117 10.5 (9.2-11.9)
Abdominal 22 60/856 7.0 (5.4-8.9)
Neck or extremity 8 9/128 7.0 (3.5-12.5)
Physiologic predictors
Prehospital CPR
Yes 9 22/425 5.2 (3.4-7.6)
No 8 41/301 13.6 (10.1-

17.9)
ED signs of life
Yes 35 290/1523 19.0 (17.1-

21.1)
No 33 62/2166 2.9 (2.2-3.6)
ED cardiac rhythm
Asystole 8 10/382 2.6 (1.4-4.6)
Pulseless electrical activity 3 17/152 11.2 (6.9-17.0)
Sinus 3 21/63 33.3 (22.6-

45.6)
Other 5 4/83 4.8 (1.6-11.2)
ED vital signs
Yes 25 241/1382 17.4 (15.5-

19.5)
No 35 135/3516 3.8 (3.2-4.5)
Overall
EDT hospital survival 71 871/10,238 8.5 (8.0-9.1)
EDT neuro intact hospital survival 47 408/6746 6.1 (5.5-6.6)
Percentage EDT survivors neurologically intact 45 466/544 85.7 (82.5-

88.4)
All described predictors of EDT were analyzed individually across all studies.
CPR: Cardiopulmonary resuscitation; ED: Emergency department; EDT: Emergency department thoracotomy
From: Seamon MJ, Haut ER, Van Arendonk K, et al. An evidence-based approach to patient selection for emergency
department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma
Acute Care Surg 2015; 79:159. DOI: 10.1097/TA.0000000000000648. Copyright © 2015 American Association for the
Surgery of Trauma. Reproduced with permission from Wolters Kluwer Health. Unauthorized reproduction of this material is
prohibited.
Contributor Disclosures
Julie M Winkle, MD, FACEP, FCCM Nothing to disclose Eric Legome, MD Nothing to disclose Maria E
Moreira, MD Nothing to disclose Jonathan Grayzel, MD, FAAEM Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform to
UpToDate standards of evidence.
Conflict of interest policy

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Initial evaluation and management of penetrating thoracic

ANATOMY, PATHOPHYSIOLOGY, AND MECHANISM

Common mechanisms and associated injuries by location

● Subcutaneous air (crepitus) strongly suggests a tracheobronchial injury or a pneumothorax,

Pneumothorax — Pneumothorax should be suspected in any patient with penetrating chest

INITIAL EVALUATION AND MANAGEMENT

Low-volume resuscitation (or "permissive hypotension"), as part of a "damage-control resuscitation"

Extended Focused Assessment with Sonography in Trauma — The Extended Focused

An abdominal ultrasound examination showing intraperitoneal free fluid following thoracoabdominal

Thoracoabdominal trauma — Thoracoabdominal wounds present a diagnostic challenge as

Other important injuries may be detected on AP chest radiograph. Radiographic findings of

Thoracic ultrasound — We recommend that an ultrasound examination of the chest (E-FAST) be

Chest computed tomography (CT) — Indications for obtaining a chest CT in a hemodynamically

● Trajectory of a penetrating object crosses the mediastinum or middle of the chest.

CT is useful for excluding intraabdominal injury in hemodynamically stable patients with

Esophagoscopy and esophagography — An esophagram is usually performed in any patient with

of aspiration [70,71]. Flexible esophagogastroduodenoscopy (EGD) is an alternative approach but is

Bronchoscopy — Bronchoscopy is the diagnostic modality of choice to confirm injuries to the

DISPOSITION AND DEFINITIVE MANAGEMENT

Occult pneumothorax — The management of occult pneumothorax, defined as a pneumothorax

Indications for operative management — Approximately 15 percent of patients with penetrating

EMERGENCY DEPARTMENT THORACOTOMY (EDT)

massage. The performance of EDT is discussed separately. (See "Resuscitative thoracotomy:

We believe that EDT is justified if the following conditions are met:

● Patient manifests signs of life in the field or the hospital, AND

● A thoracic or trauma surgeon is available within approximately 45 minutes

We believe that EDT is futile in the following circumstances:

● Patient has no pulse or blood pressure in the field

● Asystole is the presenting rhythm, and there is no pericardial tamponade

● Prolonged pulselessness (over 15 minutes) occurs at any time

● Massive, nonsurvivable injuries have occurred

● No thoracic or trauma surgeon is available within approximately 45 minutes

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is being investigated as a

"Endovascular methods for aortic control in trauma".)

Practice Management Guidelines published by the American College of Surgeons Committee on

● Patients undergoing cardiopulmonary resuscitation (CPR) on arrival to the hospital should be

● Indications for RT include the following:

• Blunt trauma patients with less than 10 minutes of prehospital CPR

SOCIETY GUIDELINE LINKS

SUMMARY AND RECOMMENDATIONS

● Immediate tracheal intubation of patients with pericardial tamponade or a tension pneumothorax

Use of UpToDate is subject to the Subscription and License Agreement.

7. Scope A, Farkash U, Lynn M, et al. Mortality epidemiology in low-intensity warfare: Israel

53. Ordog GJ, Wasserberger J, Balasubramanium S, Shoemaker W. Asymptomatic stab wounds of

79. Working Group, Ad Hoc Subcommittee on Outcomes, American College of Surgeons.

88. Inaba K, Chouliaras K, Zakaluzny S, et al. FAST ultrasound examination as a predictor of

Topic 13862 Version 28.0

This posterior-anterior (PA) radiograph of the chest reveals a left pneumothorax.

Graphic 53428 Version 3.0

Intracardiac hemodynamic tracings showing acute cardiac

Graphic 55709 Version 4.0

Chest radiograph showing pneumomediastinum

Courtesy of Pierre J Sasson, MD.

Graphic 69215 Version 4.0

This axial CT of the chest with lung windows demonstrates extensive

CT: computed tomography.

Courtesy of Pierre J Sasson, MD.

Graphic 82669 Version 4.0

Chest x-ray with apical pneumothorax

The film demonstrates a small left apical spontaneous pneumothorax. The

Graphic 72656 Version 3.0