Initial evaluation and management of penetrating thoracic trauma in adults

INTRODUCTION — Penetrating thoracic trauma can present with a wide range of injuries, ranging from superficial wounds to hemodynamic instability requiring immediate life-saving interventions. Even apparently stable patients with penetrating thoracic injuries can deteriorate precipitously, thus a focused evaluation must be rapidly performed to assess for life-threatening conditions. According to retrospective studies, thoracic injuries are a relatively common cause of preventable death among trauma patients [1,2].

Although penetrating thoracic trauma is more deadly than blunt trauma, most penetrating injuries do not require major operative intervention, and many patients are managed with observation and serial evaluation, while some need only tube thoracostomy. Approximately 15 to 30 percent of penetrating thoracic injuries require surgery, as opposed to less than 10 percent of injuries from blunt thoracic trauma.

This topic review will discuss the epidemiology, mechanisms, and general approach to the initial management of intrathoracic injuries sustained by adults with penetrating thoracic trauma. Blunt thoracic trauma, thoracic trauma in children, trauma limited to the chest wall, and definitive management of specific injuries are reviewed separately.

●(See "Initial management of trauma in adults".)

●(See "Initial evaluation and management of blunt thoracic trauma in adults".)

●(See "Thoracic trauma in children: Initial stabilization and evaluation".)

●(See "Initial evaluation and management of chest wall trauma in adults".)

EPIDEMIOLOGY — Thoracic wall penetration occurs most often from gunshots and stabbings, while less common causes are impaling injuries from industrial accidents, falls, collisions, blast injuries, and fragmenting military devices. Data from law enforcement suggest that wearing body armor improves chance of surviving when being shot at the torso [3].

The incidence of penetrating thoracic trauma varies geographically. In the United States, penetrating thoracic trauma accounts for approximately 3 percent of all trauma-related deaths [4,5]. In Europe, the incidence of penetrating trauma is reported to be as low as 4 percent [6]. Urban centers tend to have higher rates of interpersonal violence and a correspondingly higher percentage of injuries involve penetrating mechanisms compared with rural regions. In countries or regions engaged in warfare, up to 95 percent of military deaths may result from a penetrating mechanism [7].

The exact incidence of specific injuries 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.

ANATOMY AND MECHANISM

Thoracic anatomy — 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 Injury Patterns'.)

●Chest wall – Low-energy mechanisms, such as stab wounds, may cause 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. Chest wall anatomy in relation to trauma is discussed in detail elsewhere; this topic covers injuries to intrathoracic structures. (See "Initial evaluation and management of chest wall trauma in adults", section on 'Anatomy and Injury Patterns'.)

●Lungs – Lung injuries from penetrating trauma are common. Pneumothorax occurs in the great majority of patients with transpleural penetrating chest injuries. Pulmonary contusion is a common injury after high-energy penetrating chest trauma [9]. Other injuries include hemothorax, pulmonary laceration, and any combination of the above. (See 'Pulmonary contusion' below and 'Hemothorax and vascular injury' below.)

●Heart – The right ventricle is the most commonly injured chamber in penetrating trauma due to its anterior position within the chest cavity [10,11]. The next most common is the left ventricle. Atrial injuries are less common and generally less severe. Multichamber injuries cause the highest mortality. Cardiac anatomy in relation to trauma is discussed in detail elsewhere. (See "Management of cardiac injury in severely injured patients", section on 'Anatomy and mechanism of injury'.)

●Great vessels – Major arteries within the thorax include the aorta, the brachiocephalic trunk, the left subclavian artery, and left common carotid artery (figure 1). Major veins include the superior vena cava, innominate veins, and right and left subclavian veins. Patient with penetrating injuries to major thoracic vessels rarely present for care since most with such wounds expire in the field, but may present to the hospital if the bleeding is contained in a hematoma or the pleural space [12]. Thoracic vascular anatomy in relation to trauma is discussed in detail elsewhere. (See "Overview of blunt and penetrating thoracic vascular injury in adults", section on 'Specific anatomic sites'.)

●Tracheobronchial tree – Injuries to the tracheobronchial tree are less common in penetrating trauma than in blunt trauma and generally involve the cervical trachea [8]. (See 'Tracheobronchial injury' below.)

●Esophagus – Esophageal injuries are uncommon and lack specific clinical signs or chest radiographic findings, but need early diagnosis to avoid dangerous complications [13]. Esophageal anatomy in relation to trauma is discussed in detail elsewhere. (See "Overview of esophageal injury due to blunt or penetrating trauma in adults", section on 'Anatomy and injury grading'.)

●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 up to 5cm from its normal position during pregnancy, thus penetrating wounds of the thorax can involve intra-abdominal organs as well. Diaphragm anatomy in relation to trauma is discussed in detail elsewhere. (See "Recognition and management of diaphragmatic injury in adults", section on 'Anatomy of the diaphragm'.)

Common mechanism of injury

Stab wounds — 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 [14]. 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 stab wounds to "the cardiac box" because of the high risk of injury to the heart and other mediastinal structures [15]. The box is defined superiorly by the clavicles and sternal notch, laterally by the nipple line, and inferiorly by the costal margins (figure 2).

Gunshot wounds — Gunshot wounds and other higher velocity implements or debris have a less predictable pattern of injury. The trajectory of a missile once inside the body 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

General principles

●Transport site – 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, preferably directly to a trauma center whenever possible. Retrospective studies suggest that mortality is reduced when severely injured patients are transported directly to a trauma center [16-20].

●Acute management of shock or respiratory distress – Patients with signs of shock or respiratory distress should be transported immediately. Scene time should be minimized and only emergency life-saving interventions (ie, tracheal intubation, needle decompression of a tension pneumothorax) should delay transport [21]. Intravenous (IV) access and fluid resuscitation may be initiated while en route to the hospital [12,22]. Hemorrhage control and fluid resuscitation for trauma patients is discussed in detail separately. (See "Initial management of moderate to severe hemorrhage in the adult trauma patient".)

●Cervical spine stabilization – 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 [23,24]. 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'.)

●Sucking chest wounds – 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.

Role of needle/finger chest decompression — Tension pneumothorax can cause acute respiratory distress and cardiovascular collapse. External signs of chest trauma with severe dyspnea, asymmetric breath sounds, and hypotension are highly suggestive of tension pneumothorax, but other physical findings, such as diminished breath sounds, distended neck veins, and tracheal deviation, can be unreliable [25,26]. In an intubated patient, airway resistance increases and bag-mask ventilation becomes difficult [27].

Needle or finger thoracostomy may be life-saving for patients in shock from a tension pneumothorax; however, it can be difficult to determine when prehospital thoracostomy should be performed. Needle or finger thoracostomy itself will create a pneumothorax if performed when tension pneumothorax is absent and may not be effective when a tension pneumothorax is localized [28]. Thus, we suggest performing either a needle or finger thoracostomy if there is high clinical suspicion of a tension pneumothorax from penetrating thoracic injury and one of the following conditions is present [25-27]:

●Respiratory distress or low pulse oximetry despite supplemental oxygen with asymmetric breath sounds

●Hemodynamic instability or signs or shock

●Transport time will be prolonged

●Cardiac arrest (bilateral emergent needle thoracostomies are warranted)

The choice of technique is dependent on operator experience and comfort, taking into account the patient's body habitus (eg, a needle thoracostomy is more likely to be successful in a thin patient).

Several studies have evaluated the utility of prehospital needle decompression for suspected tension pneumothorax [29-34]. In a large, prospective, observational study, researchers at a major urban trauma center assessed the frequency and utility of needle thoracostomy in over 6000 trauma patients and found that the procedure, while seldom performed, may improve outcome in a small number of patients [31]. In a retrospective review of 143 multisystem trauma patients, needle decompression was more successful when performed for hypoxia as compared with hemodynamic instability or cardiac arrest; additionally, vital sign parameters were more likely to predict technical success compared with clinical examination findings [32].

Other studies have questioned the utility of needle thoracostomy in the prehospital setting. In an observational study with more than 2000 trauma patients, 19 received prehospital needle decompression, but only four showed evidence of tension physiology, defined by the presence of a pneumothorax with an air leak, after tube thoracostomy suggesting that needle thoracostomy is often ineffective and overused [30]. A study of 33 medical and trauma patients who received needle decompression found that 14 patients who presented in cardiac arrest had no change in outcome, and only 10 patients had clinical evidence of a pneumothorax [29]. None of the four patients who survived had hemodynamic or respiratory instability prior to decompression.

Finger thoracostomy is an alternative pleural decompression technique recently introduced to the prehospital setting [33,35]. Since a finger has to enter the pleural space, finger thoracostomy may have a better chance of pleural decompression with less risk of lung injury compared with needle thoracostomy. However, greater training is needed and there is a risk of injuring the finger if a fractured rib is present. A systematic review of 19 studies found that mortality was similar for the finger and needle technique [33]. Patients who received a finger thoracostomy had fewer procedural complications, higher rate of pleural cavity access, and better rate of vital signs improvement. However, study protocols and outcome definitions were heterogenous, thus limiting conclusions regarding which technique is optimal.

Following either needle or finger chest decompression, tube thoracostomy is typically performed. (See "Thoracostomy tubes and catheters: Indications and tube selection in adults and children".)

Needle thoracostomy location — Acceptable sites for insertion of a 14-gauge angiocatheter include the second or third intercostal space (ICS) in the midclavicular line, or the fifth ICS in the anterior or midaxillary line. Decompression appears to be easier to perform and more often successful when needle thoracostomy is performed in the fourth or fifth ICS using a longer needle (8 cm versus 5 cm) [36-38]. Regardless of site, needles longer than 7 cm (as long as 8 cm) should be used to perform the technique effectively [34,36,39-46].

The Advanced Trauma Life Support (ATLS) curriculum has adopted this approach in adults and recommends performing chest decompression at the fifth ICS in the midaxillary line, rather than the second ICS in the midclavicular line. Despite ATLS recommendations, in patients with obesity, needle decompression at the anterior or midaxillary line fifth ICS may have a higher failure rate compared with the midclavicular line second ICS because the chest wall is significantly thicker at the fifth ICS [47]. Additionally, in the prehospital setting, anterior placement in the second or third ICS has the advantage of permitting direct stabilization and continued observation while in a moving ambulance. Catheters placed at the lateral site may be dislodged by the patient's arm and may be more prone to obstruction [48].

Finger thoracostomy technique — The following is a description of a finger thoracostomy technique [35]:

●Place the patient supine with the arm on the affected side abducted

●Use a scalpel to make a 2 cm incision directly over the fifth rib at the mid-axillary line

●Use curved forceps to bluntly dissect

●Insert the forceps through the intercostal muscles, over the rib into the pleural space

●Fully open the forceps and then remove

●Insert a finger and perform a finger-sweep to free adhesions and ensure pleural decompression

●Cover wound with stoma dressing (no catheter is inserted into the space)

INITIAL EVALUATION AND MANAGEMENT

Primary survey — Rapid assessment of the patient with penetrating chest trauma is essential. The primary survey of Advanced Trauma Life Support (ATLS) 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. 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'.)

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.

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. If in a community hospital where there is only one clinician experienced in trauma care, each element of the primary survey should be definitively addressed before proceeding to the next section (eg, place chest tube for tension pneumothorax before assessing circulation).

Airway — Assessment of the airway to determine its patency and the need for tracheal intubation is generally the first step of the primary survey [49]. The patient’s initial appearance may provide the clinician with a clear sense of their condition and need for airway management. Respiratory distress, diaphoresis, combativeness, or an unwillingness to lie flat may signal active or imminent cardiopulmonary decompensation.

If pericardial tamponade or a tension pneumothorax is suspected based on clinical examination (see 'Breathing' below) or extended focused assessment with sonography in trauma (E-FAST) examination, immediate tracheal intubation and positive pressure ventilation can exacerbate hypotension and even cause cardiovascular collapse due to increased intrathoracic pressure and decreased venous return. Whenever possible, evacuation of the pericardial effusion or decompression of the pneumothorax should be performed first, while the patient is prepared for intubation. Since these are painful procedures, thoracostomy or pericardiocentesis should ideally be performed simultaneously with tracheal intubation if there is sufficient personnel available.

If time and patient stability allows and resources are available, tracheal intubation is preferably performed in the operating room. 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 or even require tracheal intubation, 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 "Overview of advanced airway management in adults for emergency medicine and critical care" and "Rapid sequence intubation in adults for emergency medicine and critical care" and "Airway management in the adult with direct airway trauma for emergency medicine and critical care".)

Breathing — Breathing assessment in penetrating chest trauma includes inspection of the chest wall for wounds and 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.

Tension pneumothorax or hemothorax can cause severe acute respiratory distress and cardiovascular collapse. External signs of chest trauma with severe dyspnea, asymmetric breath sounds, and hypotension is highly suggestive of tension pneumothorax, but physical findings, such as diminished breath sounds, distended neck veins, and tracheal deviation, can be unreliable [25,26]. In an intubated patient, airway resistance increases and bag-mask ventilation becomes difficult [27].

●Cover any "sucking" chest wounds (ie, air entering the pleural cavity via a wound during inspiration) with an occlusive dressing taped on three sides to seal off air entry and prevent the expansion of a pneumothorax.

●If the clinician suspects a tension pneumothorax or hemothorax and the patient is hemodynamically unstable or shows signs of severe respiratory distress, a thoracostomy (chest) tube is inserted immediately [49]. If thoracostomy is needed for a penetrating injury in an unstable patient, use a 24 to 28 French chest tube [50,51]. Needle or finger decompression may be performed initially if placing the chest tube must be delayed. (See 'Needle thoracostomy location' above and 'Finger thoracostomy technique' above and "Thoracostomy tubes and catheters: Indications and tube selection in adults and children", section on 'Tension pneumothorax'.)

Circulation — Circulation assessment in penetrating trauma includes checking pulses in all extremities, obtaining blood pressure, evaluating mental status and skin perfusion, and performing point-of-care ultrasound (eg, E-FAST). (See 'E-FAST' below.)

Shock is most often hemorrhagic, but can also be obstructive from a tension pneumothorax or cardiac tamponade. If placement of unilateral or bilateral tube thoracostomies does not correct perfusion, an ultrasound pericardial examination or emergency pericardiocentesis (if bedside ultrasound is not available or adequate pericardial ultrasound views cannot be obtained) is the next step. Any actively exsanguinating external wounds should be addressed, whether with direct pressure, proximal occlusion (eg, tourniquet or a manual blood pressure cuff), or placement of staples or sutures.

In patients with signs of hemorrhagic shock, blood products should be given as soon as the need for transfusion is recognized in a 1:1:1 ratio of red blood cells, plasma, and platelets. Isotonic crystalloid in lieu of blood can be given initially, but unnecessary infusion of crystalloid should be avoided since it can dilute clotting factors, contribute to hypothermia, and disrupt thrombus. Diagnosis and treatment of shock in the adult trauma patient is discussed in detail separately. (See "Initial management of moderate to severe hemorrhage in the adult trauma patient" and "Approach to shock 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. 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. 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".)

E-FAST — 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. We recommend performing an E-FAST examination in all patients with penetrating chest trauma, but to not delay necessary interventions (eg, thoracostomy, thoracotomy, transfer to operating room) to perform the E-FAST. Ultrasound is easily portable, immediately available, non-invasive, and accurately detects the presence of hemopericardium, pneumothorax, hemothorax, and intraperitoneal fluid, thereby determining which patients need immediate invasive intervention. 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".)

In a patient with penetrating thoracoabdominal trauma, a negative E-FAST does not definitively exclude intra-abdominal injury, such as to the diaphragm or hollow viscous, and further evaluation with serial abdominal examinations, diagnostic peritoneal tap and lavage, computed tomography (CT), or exploratory surgery is required [52].

The three targets of the E-FAST examination are the heart, lungs, and abdomen:

●Pericardial examination – Ultrasound identifies hemopericardium with high sensitivity, specificity, and accuracy. However, there are case reports of false-negative examinations, mostly in patients with concurrent, large hemothoraces, or mediastinal hemorrhage. To improve accuracy in such cases, we recommend repeating the pericardial ultrasound examination 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'.)

●Pleural examination – Ultrasound appears to have superior sensitivity and similar specificity to supine anteroposterior (AP) chest radiography for the identification of pneumothorax in adults. 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. Ultrasound can also detect hemothorax. Performance of the ultrasound examination in the setting of thoracic trauma and the ultrasound findings associated with the presence of a pneumothorax and hemothorax are discussed in greater detail separately. (See "Emergency ultrasound in adults with abdominal and thoracic trauma", section on 'Pleural examination' and "Emergency ultrasound in adults with abdominal and thoracic trauma", section on 'Pneumothorax and hemothorax'.)

●Abdominal examination – In hemodynamically unstable thoracoabdominal trauma patients, ultrasound identification of intraperitoneal free fluid assists in rapidly prioritizing operative interventions. (See "Emergency ultrasound in adults with abdominal and thoracic trauma", section on 'Abdominal examination'.)

Role of emergency department thoracotomy

Overview and survival — Emergency department thoracotomy (EDT) is performed to resuscitate trauma patients who have just sustained or are on the verge of cardiac arrest. Several potentially life-saving maneuvers can be performed via a left anterolateral thoracotomy, 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 on the location and mechanism of injury and whether signs of life were present upon arrival at the hospital [53-57]. According to systematic reviews, patients with isolated stab wounds to the chest who show signs of life at presentation are most likely to survive following EDT (17 percent compared with 4 percent for either gunshot wound or abdominal injury) [53,54,58]. Survival rate after EDT decreases if patients lose signs of life en route to the hospital or have no signs of life in the field (9 and 1 percent, respectively). Survival is rare in patients with multiple gunshot wounds to the chest [59-61]. Survival data from a review performed by the Eastern Association for the Surgery of Trauma (EAST), including neurologically-intact survival, are summarized in the accompanying table (table 1) [58].

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is being investigated as a possible alternative to EDT in select critical trauma patients. (See "Endovascular methods for aortic control in trauma".)

Indications and contraindications — Hospitals should develop policies to determine the indications and circumstances when EDT is performed since the procedure entails risks and requires significant resources, diverting care from other patients. Risks of EDT include transmission of communicable diseases (eg, human immunodeficiency virus [HIV], hepatitis) and iatrogenic injury from sharp instruments, suture needles, and open rib fractures [62].

We believe that EDT is justified if the following conditions are met [54,55,58]:

●Patient manifests signs of life (spontaneous breathing, palpable carotid pulse, measurable blood pressure, electrical cardiac activity, pupillary response to light, or spontaneous extremity movement [54,63]) 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

We believe that EDT is futile in the following circumstances [54,55,58]:

●Patient has no pulse or blood pressure in the field (ie, on initial evaluation by emergency medical personnel)

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

●Ultrasound pericardial examination shows absence of both pericardial fluid and cardiac motion [64]

●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

The time frame in which a surgeon should be available following EDT is an approximation based on expert opinion, given the logistics of community emergency medicine practice. However, this time frame can vary depending upon physician judgment and clinical circumstances. As examples, a longer period might be appropriate while awaiting the surgeon's arrival 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.

Various surgical organizations have published practice guidelines for EDT, although societies and experts continue to debate the appropriate indications and contraindications. EAST used the GRADE methodology to formulate recommendations for the appropriate use of EDT, including the following [58]:

●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.

Secondary survey — 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. In a hemodynamically unstable patient with penetrating thoracic trauma, do not delay definitive management (eg, transfer to operating room, angiography suite or trauma center) to perform a more detailed secondary evaluation. The secondary survey is discussed in detail separately. (See "Initial management of trauma in adults", section on 'Secondary evaluation and management'.)

Patients with penetrating thoracic trauma can deteriorate rapidly, and neither stable vital signs nor the initial absence of symptoms excludes the presence of a life-threatening injury. In patients with evidence of pulmonary injury (eg, contusion or pneumothorax), obtain continuous pulse oximetry monitoring. Reevaluate the primary and secondary surveys, including repeating E-FAST exam, if there is any change in the patient's clinical status.

Signs concerning for underlying 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:

●Any vital sign abnormality, especially hypotension, hypoxia, or persistent tachycardia. Young, healthy patients or older adults in shock may not present in typical fashion. (See "Geriatric trauma: Initial evaluation and management" and "Approach to shock in the adult trauma patient".)

●Persistent dyspnea or pleuritic chest pain suggests injury to the lungs or pericardium.

●Hematomas and air bubbling through chest wounds suggest lung injury.

●A foreign body sensation in the throat, a change in voice, or stridor 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. Physical examination has not been shown to be sufficiently sensitive to rule out a pneumothorax or hemothorax from penetrating trauma, although sensitivity appears to increase with increasing size of the pneumothorax [14,65,66].

●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.

●Diminished or absent pulses suggests vascular injury.

●Subcutaneous air (crepitus) strongly suggests a tracheobronchial injury or a pneumothorax, either large or small. Both injuries must be considered.

●Odynophagia, dysphagia, hematemesis, chest pain, or back pain, followed by fever, dyspnea, and chest wall crepitus suggests esophageal injury.

●Hamman's sign is a crunching sounds heard over the precordium (movie 1) that occurs with pneumomediastinum.

DIAGNOSTIC TESTING IN STABLE/STABILIZED PATIENT

Overview of testing — A plain chest radiograph (CXR) 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. If the focused assessment with sonography in trauma (FAST) examination was not performed during the primary survey, it should be performed as part of the diagnostic testing. Further testing is determined based on the patient's signs and symptoms as well as the location of the penetrating wound (algorithm 1).

Chest radiograph (all patients) — All hemodynamically stable patients should have at least a supine anteroposterior (AP) CXR; a posteroanterior (PA) CXR with the patient upright is preferable if they are not severely injured (eg, spinal injury, long bone fractures). Retrospective studies suggest that CXR taken during expiration does not increase the sensitivity for detecting pneumothorax [67,68].

Injuries may not manifest initially and the CXR at presentation has poor sensitivity in detecting injuries, such as pneumothorax and hemothorax. Some studies report sensitivity for pneumothorax as low as 36 to 48 percent for supine AP films (image 1 and image 2) [69-71]. Studies showed that 2 to 12 percent of asymptomatic patients with a normal initial AP CXR are at risk for subsequently developing a pneumothorax or hemothorax. However, the negative predictive value of CXR increases to nearly 100 percent if repeated six hours after presentation [72]. Several small studies have found that a normal repeat upright PA CXR performed at three hours is likely as sensitive as a repeat CXR done at six hours [73-75]. While this is not our approach, some centers shorten the observation time and repeat the CXR three hours after injury.

CXR can miss injuries to a number of vital structures, including the heart, great vessels, esophagus, and trachea [76-78]. However, important injuries may be detected on CXR, such as the following:

●Pulmonary contusions can cause patchy, irregular, alveolar infiltrates to frank consolidation. Usually these changes are present on the initial examination and worsen over several hours [79].

●Esophageal injuries can cause cervical emphysema, pneumomediastinum, alteration of the mediastinal contour, and left pleural effusion.

●Hemopericardium can cause the straight left heart border sign (filling in of the left heart border inferior to the pulmonary artery). 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 [80].

●Rib fractures may also be identified.

●Retained ballistic fragments are typically radiopaque.

Findings suggesting aortic injury are discussed elsewhere. (See "Initial evaluation and management of blunt thoracic trauma in adults", section on 'Abnormal CXR findings'.)

Candidates for chest CT — We suggest obtaining a computed tomography (CT) if there is clinical suspicion for an intrathoracic injury, which is essentially the case for all penetrating thoracic trauma except for the obvious superficial wound or stab wound outside the cardiac box. Common 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 (eg, stab wound to the "cardiac box") (figure 2).

●Symptoms or signs concerning for esophageal or tracheobronchial or vascular injury are present. (See 'Signs concerning for underlying injury' above.)

●Chest pain, shortness of breath, or other symptoms consistent with injury are present that are not explained adequately by a CXR.

CT of the chest has the best sensitivity and specificity for detecting pneumothorax and hemothorax, as well as injuries to intrathoracic structures missed by CXR. However, CT exposes the patient to higher radiation levels compared with CXR and to the risks of intravenous (IV) contrast administration. (See "Radiation-related risks of imaging", section on 'CT examinations' and "Contrast-associated and contrast-induced acute kidney injury: Clinical features, diagnosis, and management".)

●CT chest versus serial CXR – Most centers choose to perform a noncontrast screening chest CT rather than serial CXR to rule out pneumothorax or other thoracic injury requiring intervention, thus expediting disposition [81,82]. In a single-center 10-year retrospective review of 386 hemodynamically stable patients with thoracic stab wounds, chest CT detected injuries not identified by CXR in up to one-third of patients, but of these 42 patients, only 16 required significant intervention (tube thoracostomy in 14 and surgery for hemopericardium in 2) [83].

●Optimal CT technique – Any patient with a knife or gunshot wound that traverses the mediastinum should be evaluated with a contrast-enhanced torso CT, ideally multidetector CT (MDCT), since it provides higher resolution and better quality images compared with older single-slice detector CT [84]. Multiphasic or delayed image acquisition better identifies vascular injuries; these preferences depend on the type of CT scanner available and institutional preferences. CT angiography is the preferred technique when vascular injury is strongly suspected and is useful in planning conservative versus operative management. (See "Overview of blunt and penetrating thoracic vascular injury in adults", section on 'Vascular imaging'.)

Approach to wounds traversing the mediastinum — Any penetrating thoracic trauma with a trajectory that passes close to mediastinal structures (ie, cardiac box) (figure 2) requires evaluation to rule out cardiac, tracheobronchial tree, and esophageal injury. This traditionally entails either FAST examination or echocardiography, bronchoscopy, and either esophagoscopy or a contrast esophagogram. However, if the wound track on MDCT does not traverse the mediastinum or travel close to vital structures, these additional studies may be unnecessary, but this decision should be made in consultation with a trauma surgeon [76,77].

●The FAST pericardial examination has supplanted formal transthoracic echocardiography for evaluation of cardiac injury. The sensitivity of the FAST pericardial examination is nearly 100 percent when the heart can be clearly visualized (eg, hemothorax does not obscure the image) [85,86]. Formal transthoracic echocardiography should be performed to rule out cardiac injury if the FAST examination cannot be performed, the pericardial views are inadequate, or findings are ambiguous. (See "Emergency ultrasound in adults with abdominal and thoracic trauma", section on 'Pericardial and limited cardiac examination'.)

●Rapid diagnosis of esophageal injuries is important because these have a high incidence of morbidity and mortality when surgical repair is delayed; early surgical repair obtains the best results and reduces morbidity [87]. CT esophagography or an esophagram is usually performed in any patient with trans-mediastinal injuries or possible injury of the esophagus (ie, presence of odynophagia, dysphagia, hematemesis, imaging with mediastinal air, left pleural effusion). The exact technique is based on institutional preference and can include the following (see "Overview of esophageal injury due to blunt or penetrating trauma in adults", section on 'Clinical features and diagnosis'):

•CT esophagography (oral contrast-enhanced MDCT) is sensitive and highly specific for the evaluation of acute esophageal injury in penetrating trauma. The accuracy of CT esophagography is at least equal to, if not superior to, that of fluoroscopic esophagography (sensitivity of 59 to 100 percent and specificity of 80 to 100 percent) in assessing for an esophageal leak [88,89].

•Initial water-soluble contrast esophagram, and if negative, then repeat esophagram with barium sulfate contrast [90].

•Single barium contrast esophagram (rather than water-soluble contrast) since increased sensitivity, superior image quality, and decreased risk of aspiration [91,92].

•Flexible esophagogastroduodenoscopy (EGD) is an alternative to imaging but is generally less favored in the acute trauma setting because of the risk of causing additional injury, such as pneumothorax.

●Bronchoscopy is the diagnostic modality of choice to confirm or exclude injuries to the tracheobronchial tree. Early diagnosis is essential to reduce morbidity and obtain a successful primary reanastomosis [93]. (See "Identification and management of tracheobronchial injuries due to blunt or penetrating trauma".)

Patients with lower thoracic wounds — Patients with 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) are considered to have thoracoabdominal wounds. These are diagnostically challenging since movement of the diaphragm makes it difficult to predict the penetrating tract. Thus, intra-abdominal and intrathoracic structures as well as the diaphragm can be injured [94]. Imaging of the abdomen should be performed to assess potential sites of intra-abdominal injury, such as the liver, spleen, aorta, and other great vessels. (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".)

SPECIFIC INJURIES

Pneumothorax

●Clinical features – Pneumothorax is the most common serious injury associated with penetrating thoracic trauma [95]. The severity of clinical findings is variable and does not necessarily correlate with size of the pneumothorax, even in the presence of a large pneumothorax, while a small pneumothorax may be clinically undetectable. The presence of unilateral diminished breath sounds or subcutaneous air (ie, emphysema) anywhere in the chest wall of a patient with penetrating thoracic trauma strongly suggests a pneumothorax.

●Diagnosis – A pneumothorax can be diagnosed by CXR, chest CT, or extended focused assessment with sonography in trauma (E-FAST) exam. (See 'Chest radiograph (all patients)' above and 'Candidates for chest CT' above.)

●Management – Tube thoracostomy without other interventions is sufficient to manage 85 percent of cases [95]. The indications for tube thoracostomy are the same as for blunt thoracic trauma and discussed elsewhere. (See "Initial evaluation and management of blunt thoracic trauma in adults", section on 'Pneumothorax'.)

Occult pneumothorax, defined as a pneumothorax seen on CT but not visible on CXR, can often be managed with observation. These are discussed in greater detail separately. (See "Initial evaluation and management of blunt thoracic trauma in adults", section on 'Occult pneumothorax'.)

Pulmonary contusion

●Clinical features – High-energy trauma can cause a pulmonary contusion, which is essentially a direct bruise of the lung that can lead to hypoxemic respiratory failure. 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 [79]. In addition, high-velocity gunshot wounds can cause clinically significant damage to the lung parenchyma.

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. Once radiographically visible infiltrates appear, crackles and rhonchi often become audible and dyspnea and hypoxia worsen.

●Diagnosis – Radiographic findings associated with pulmonary contusion include patchy or diffuse areas of infiltrate, which may initially be subtle but worsen over 24 to 48 hours, especially after large volume fluid resuscitation [96].

●Management – Pain control and pulmonary hygiene are the mainstays of management. Prophylactic endotracheal intubation is unnecessary, but patients with hypoxia or difficulty ventilating require airway management. Fluid resuscitation with crystalloid to achieve euvolemia appears appropriate despite varying opinions. Common complications include pneumonia and acute respiratory distress syndrome (ARDS), while abscesses or a bronchopleural fistula can occasionally develop. (See "Acute respiratory distress syndrome: Clinical features, diagnosis, and complications in adults" and "Acute respiratory distress syndrome: Fluid management, pharmacotherapy, and supportive care in adults".)

Hemothorax and vascular injury

●Clinical features – Hemothorax often occurs concomitantly with pneumothorax and other injuries, such as vascular injures. Patients with vascular injury (ie, subclavian injuries) can present with a contained hematoma, external bleeding or massive hemothorax. However, patients with injuries to the great vessels rarely survive to reach the hospital. Injuries to the lung parenchyma or intercostal blood vessels can also cause a hemothorax. A large hemothorax can present with diminished breath sounds and shock.

●Diagnosis – A hemothorax can be diagnosed by CXR, chest CT, or E-FAST examination. At least 300 mL of blood is needed for hemothorax to manifest on an upright CXR.

●Management – A hemothorax larger than 300 to 500 mL is treated with tube thoracostomy, traditionally using a 28 or 32 French tube, but recent studies have found that smaller tubes (14 to 22 French) have similar efficacy, complication, and failure rates [97-101]. However, the criteria in trauma patients for selecting a smaller versus larger tube are not established, and these studies tend to exclude hemodynamically unstable patients or those requiring emergent thoracostomy; thus larger tube size may still be preferable in the sicker trauma patient. Large hemothoraces that remain undrained can compromise ventilation and may not resorb, eventually causing infection and pulmonary fibrosis. Thoracostomy tube sizing is discussed in detail in a separate topic. (See "Thoracostomy tubes and catheters: Indications and tube selection in adults and children", section on 'Tube sizing'.)

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 (eg, operative thoracotomy). Vital signs, fluid resuscitation requirements, and concomitant injuries are considered when determining the need for exploration in the operating room. Many authors use an initial chest tube output of 1500 ml as the threshold for surgical exploration, but other thresholds have been described (eg, 1000 mL, 20 mL/kg) [102]. Ongoing bleeding at a rate >200 to 300 mL/hour is another common indication for chest exploration [103,104]. (See "Overview of blunt and penetrating thoracic vascular injury in adults", section on 'Tube thoracostomy'.)

Small, clinically insignificant hemothoraces (less than 300 mL) may be treated with expectant management. These are more likely to occur with blunt trauma and discussed further elsewhere. (See "Initial evaluation and management of blunt thoracic trauma in adults", section on 'Hemothorax'.)

Cardiac injury

●Clinical features – Wounds to the chest, back, neck, or abdomen can cause a cardiac injury that develops into a pericardial tamponade. Penetrating wounds of the heart often cause tamponade 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. If the rate of bleeding is slow or the pericardium periodically decompresses by emptying blood into the pleural space, patients may initially appear stable or not have distended neck veins [27]. (See "Cardiac tamponade".)

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 is often not present. JVD may be absent in hypovolemic patients. Tamponade physiology ultimately leads to diminished cardiac output, a decrease in systolic blood pressure, and a narrowing of the pulse pressure.

●Diagnosis – The pericardial view of the focused assessment with sonography in trauma (FAST) examination can rapidly confirm the diagnosis (movie 2 and movie 3). (See 'E-FAST' above and "Emergency ultrasound in adults with abdominal and thoracic trauma", section on 'Pericardial and limited cardiac examination'.)

●Management – The presence of cardiac tamponade mandates intervention with a pericardial window or median sternotomy. For hemodynamically unstable patients, emergency pericardiocentesis and placement of a catheter may be needed. However, pericardiocentesis cannot be relied upon for definitive diagnosis and provides only temporary pericardial decompression when an operative thoracotomy cannot be performed promptly. Emergency department (ED) pericardial drainage is a reasonable option when surgery is not immediately available and the patient is hypotensive or otherwise hemodynamically unstable. Ultrasound guidance improves safety, clinician satisfaction, and success. (See "Emergency pericardiocentesis" and "Management of cardiac injury in severely injured patients".)

If the patient is in extremis or recently lost pulses, and pericardiocentesis is unsuccessful, an emergency left lateral thoracotomy may be performed to decompress pericardial tamponade, repair a cardiac laceration, and clamp vascular or pulmonary structures. (See 'Role of emergency department thoracotomy' above.)

Tracheobronchial injury

●Clinical features – Lacerations of the trachea or bronchi allow air into the mediastinum, which can dissect into the soft tissues of the anterior neck (image 3 and image 4). This subcutaneous emphysema can be palpated on neck examination. A crunching sound (Hamman sign) (movie 1) 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.

Tracheobronchial injuries (TBI) often go unrecognized because early symptoms and signs 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.

●Diagnosis – Bronchoscopy is the diagnostic modality of choice to confirm or exclude injuries to the tracheobronchial tree.

In a patient who undergoes tube thoracostomy after penetrating injury, a massive air leak suggests a major TBI that is unlikely to heal spontaneously and is an indication for surgical exploration of the chest. A massive air leak is defined as one present during all phases of respiration, preventing full expansion of the affected lung, or impairing ventilation through diminished tidal volume [102]. (See "Identification and management of tracheobronchial injuries due to blunt or penetrating trauma".)

●Management – TBI are typically promptly repaired surgically. TBI evaluation and management is discussed in detail elsewhere. (See "Identification and management of tracheobronchial injuries due to blunt or penetrating trauma".)

Neck injuries involving the tracheobronchial tree and the esophagus are discussed separately. (See "Penetrating neck injuries: Initial evaluation and management".)

Diaphragm injury

●Clinical features – The incidence of diaphragm injuries from thoracoabdominal penetrating trauma is 11 to 19 percent, increasing to approximately 30 percent for stab wounds and 60 percent for gunshot wounds isolated to the left lower chest. [105-107]. Diaphragm injuries are difficult to diagnose since 31 percent of patients have no abdominal tenderness and 40 percent have normal chest radiographs. In asymptomatic patients with penetrating chest injuries, the risk of occult diaphragm injury is reported to be 7 percent [108]. Some diaphragm tears, especially if small, can present years after the initial injury. The negative intrathoracic pressure and the positive intra-abdominal pressure gradually leads to herniation of viscera into the chest.

Symptoms and signs of diaphragm injury include abdominal pain (often epigastric), referred shoulder pain, shortness of breath, vomiting, dysphagia, or shock. Some patients may have no symptoms or signs to suggest an injury to the diaphragm. Diaphragmatic injury cannot be ruled out solely by physical examination.

●Diagnosis – Multidetector CT (MDCT) can evaluate 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. Small tears may not be seen even with sophisticated imaging techniques. Diagnostic peritoneal lavage, which was previously used to rule out diaphragm injuries, has been supplanted by the FAST examination and other imaging modalities. Diagnostic laparoscopy or thoracoscopy can rule out a diaphragm injury and potentially repair the injury if confirmed (algorithm 2).

●Management – Diaphragm injuries are repaired by either laparoscopy, thoracoscopy, or laparotomy. Management of diaphragm injuries is discussed in detail elsewhere. (See "Recognition and management of diaphragmatic injury in adults".)

Esophageal injury

●Clinical features – Esophageal injuries have no specific associated clinical signs and are notoriously difficult to diagnose, but mortality increases substantially with delayed diagnosis [13]. Symptoms and signs may include painful swallowing, throat, neck, or chest pain, cough, hematemesis, difficulty breathing, and subcutaneous emphysema.

●Diagnosis – Any patient with possible esophageal injury should be evaluated with esophagoscopy or esophagography. (See 'Approach to wounds traversing the mediastinum' above.)

●Management – Esophageal injuries are treated with early surgical repair. Evaluation and management of esophageal injuries is discussed in detail elsewhere. (See "Overview of esophageal injury due to blunt or penetrating trauma in adults".)

DISPOSITION

Patients with suspected isolated chest wall injury — Patients with penetrating chest injuries outside the cardiac box and a normal chest radiograph (CXR) and extended focused assessment with sonography in trauma (E-FAST) examination at presentation should either be observed for a repeat CXR six hours after arrival (to identify development of a delayed pneumothorax or hemothorax) or have an initial noncontrast chest computed tomography (CT) scan (instead of a serial CXR) [81,109]. If the chest CT is normal or re-evaluation 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. (See 'Candidates for chest CT' above.)

While this is not our approach, some centers that choose not to perform chest CT will shorten the observation time and repeat the CXR three hours after injury. This approach is supported by the results of several small retrospective studies [73-75].

Transfer to a trauma center — In a patient with penetrating thoracic trauma who receives their initial care at a community or critical access hospital that is not capable of providing definitive management of their injuries, rapid transfer to a tertiary care trauma center can be life-saving [110]. Once the clinician determines that a trauma patient requires a higher level of care, transfer should be arranged as quickly as possible and not be delayed for further diagnostic evaluations (which can still occur while awaiting transport to arrive). Transfer decisions may not be straightforward in some instances and factors, such 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 have to be considered [111,112].

Even when transfer to a trauma center is anticipated or arranged, appropriate airway management and resuscitation still need to be performed. Patients meeting criteria for tube thoracostomy should have the chest tubes placed and proper placement confirmed by chest radiograph prior to transfer. 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 'Pneumothorax' above and "Emergency pericardiocentesis".)

OUTCOMES — Overall mortality is high in patients with severe penetrating thoracic trauma. However, among patients who survive to hospital admission, mortality is approximately 5 to 6 percent [113]. Approximately 15 percent of patients with penetrating thoracic trauma require surgical management. 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" and "Society guideline links: Thoracic and lumbar spine injury in adults".)

SUMMARY AND RECOMMENDATIONS

●Anatomy – 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, and thoracic vertebrae. (See 'Anatomy and mechanism' above.)

●Initial evaluation and management – Rapid assessment of the patient with penetrating chest trauma is essential (algorithm 1). The primary survey of the adult trauma patient follows Advanced Trauma Life Support (ATLS) principles. Aspects of the primary survey of particular importance to penetrating thoracic trauma include the following (see 'Primary survey' above):

•Airway – Immediate tracheal intubation of patients with pericardial tamponade or a tension pneumothorax can exacerbate hypotension and even cause cardiovascular collapse. Whenever possible, evacuation of the pericardial effusion or decompression of the pneumothorax should be performed before or simultaneously with intubation. (See 'Airway' above.)

•Breathing – In a patient with asymmetric breath sounds and hemodynamic instability or respiratory distress, immediately insert a thoracostomy (chest) tube for a presumed tension pneumothorax. Needle or finger decompression may be performed first if there is any delay in placing the chest tube. (See 'Breathing' above and 'Role of needle/finger chest decompression' above.)

•Circulation – The best approach to volume resuscitation in patients with isolated penetrating thoracic trauma remains controversial. 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 'Circulation' above and "Initial management of moderate to severe hemorrhage in the adult trauma patient".)

The extended focused assessment with sonography in trauma (E-FAST) examination should be performed as part of the "C" evaluation in patients who do not proceed immediately to the operating room upon arrival. (See 'E-FAST' above.)

●Role of emergency department thoracotomy (EDT) – Survival following EDT is greatest among patients with isolated stab wounds to the heart who show signs of life at presentation (table 1). We believe that EDT is justified in a patient with penetrating chest trauma who has just sustained or is on the verge of cardiac arrest if the following conditions are met (see 'Role of emergency department thoracotomy' above):

•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

●Alarming clinical features – 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, abnormal pulses, and subcutaneous air. (See 'Signs concerning for underlying injury' above.)

●Diagnostic testing – The E-FAST examination and plain chest radiography (CXR) are performed in nearly all cases that do not require immediate transfer to the operating room. A contrast-enhanced torso computed tomography (CT) scan, ideally multidetector CT (MDCT) since it provides higher resolution and better quality images, is performed on most patients, except those with the obvious superficial wound or stab wound outside the cardiac box (figure 2). (See 'Diagnostic testing in Stable/Stabilized Patient' above.)

Any penetrating thoracic trauma with a trajectory that passes close to mediastinal structures (ie, cardiac box) (figure 2) requires evaluation to rule out cardiac, tracheobronchial tree, and esophageal injury. This has traditionally entailed echocardiography (supplanted now by focused assessment with sonography in trauma [FAST] examination), esophagoscopy or esophagography, and bronchoscopy. (See 'Approach to wounds traversing the mediastinum' above.)

●Management of specific injuries

•Pneumothorax and hemothorax are typically treated with tube thoracostomy. Indications for operative thoracotomy include persistent air leak and significant hemorrhage. (See 'Pneumothorax' above and 'Hemothorax and vascular injury' above.)

•Pericardial tamponade from cardiac injury can be temporized with emergency department (ED) pericardiocentesis, but ultimately mandates intervention with a pericardial window or median sternotomy. (See 'Cardiac injury' above.)

•Tracheobronchial, diaphragm, and esophageal injuries are typically managed with surgical repair. (See 'Tracheobronchial injury' above and 'Diaphragm injury' above and 'Esophageal injury' above.)

•Pulmonary contusions may initially be subtle, but worsen over 24 to 48 hours, and are treated with respiratory support. (See 'Pulmonary contusion' above.)

●Disposition – Asymptomatic patients with penetrating thoracic injuries and a normal CXR and E-FAST examination at presentation should either be observed for a repeat CXR six hours after arrival (to identify development of a delayed pneumothorax or hemothorax) or have an initial noncontrast chest CT (instead of a serial CXR). If the chest CT is normal or a repeat examination and CXR performed six hours after arrival are normal, they can be discharged with instructions to return immediately should any concerning symptoms (eg, increasing shortness of breath, painful swallowing) develop. (See 'Patients with suspected isolated chest wall injury' above.)