Thoracic injuries account for approximately 15%–20% of all trauma cases, with a higher incidence during wartime. The severity of thoracic injuries depends not only on the extent and degree of damage to the bony thorax and thoracic organs but also on the level of respiratory and circulatory dysfunction caused by the injury. The core structure of the chest, supported by the bony thorax, protects vital organs such as the lungs, heart, and great vessels, and plays a significant role in maintaining respiratory and circulatory functions. The bilateral negative pressure of the pleural cavities maintains the mediastinum in a central position. When air or fluid accumulates in one pleural cavity, it directly compresses the lung on the affected side, causes mediastinal shift, compresses the lung on the opposite side, and twists the vena cava, impairing blood return and leading to respiratory and circulatory dysfunction.
Classification
Thoracic injuries can be classified into blunt injuries and penetrating injuries based on the nature of the traumatic force. They are also divided into closed and open injuries depending on whether the pleural cavity communicates with the external environment. Blunt thoracic injuries often result from deceleration forces, compression, impact, or blunt trauma. The injury mechanisms are complex and may disrupt the integrity of the bony thorax, while subjecting the heart and lungs to impact, compression, rotation, or torsion, causing widespread tissue contusion. Patients with blunt thoracic injuries often present with rib or sternal fractures, frequently accompanied by injuries in other regions. Organ and tissue damage is commonly in the form of contusions and lacerations. Extensive pulmonary and cardiac contusions may lead to secondary complications such as acute lung injury, heart failure, and arrhythmias. Early clinical manifestations may be subtle, increasing the risk of misdiagnosis or delayed diagnosis. Most blunt thoracic injuries are closed injuries.
Penetrating thoracic injuries typically result from firearm or sharp object trauma. The extent of injury is often directly related to the wound path, making early diagnosis relatively straightforward. Progressive bleeding and secondary respiratory and circulatory dysfunction caused by organ and tissue lacerations are the main reasons for rapid deterioration and, in some cases, patient death.
Based on the severity and timeline of life-threatening complications, thoracic injuries can be categorized into:
- Rapidly Fatal Injuries, which often result in immediate death on-site. Examples include aortic rupture, cardiac rupture, cardiac arrest, and airway obstruction.
- Early Fatal Injuries, which may endanger life within a short time frame (1–2 hours) post-injury. Examples include tension pneumothorax, open pneumothorax, progressive or massive hemothorax, cardiac tamponade, and aortic contusions or dissections.
- Potentially Delayed Fatal Injuries, including flail chest, esophageal rupture, diaphragmatic rupture, pulmonary contusion, and blunt cardiac contusion. Rapid and effective treatment should be administered for rapidly fatal thoracic injuries during both pre-hospital care and hospital emergency management. Evidence of potentially life-threatening conditions should also be carefully monitored and assessed.
Emergency Management
Emergency management of thoracic injuries involves both pre-hospital care and in-hospital emergency treatment.
Pre-Hospital Care
This includes initial resuscitation and emergency management of rapidly fatal thoracic injuries at the scene. The focus is on maintaining airway patency, providing respiratory support and oxygen supplementation, controlling hemorrhage, replenishing blood volume, administering analgesia, stabilizing fractures of long bones, and protecting associated spinal injuries (especially cervical spine injuries), followed by expeditious transport to a medical facility. For patients with rapidly fatal thoracic injuries, emergency interventions at the scene are necessary, such as clearing the airway and providing artificial respiratory support if needed. Tension pneumothorax requires placement of a chest needle with a one-way valve or closed thoracic drainage. Open pneumothorax necessitates covering and sealing of sucking chest wounds, along with the placement of drainage tubes or needles. For flail chest injuries with extensive chest wall softening, effective pain control is essential, and artificial positive-pressure ventilation may be required if necessary.
In-Hospital Emergency Treatment
Timely and accurate diagnosis of rapidly and early fatal thoracic injuries is crucial, alongside the identification of evidence for potentially fatal injuries. Emergency thoracotomy is indicated in cases such as:
- Progressive massive hemothorax.
- Cardiac or great vessel injury.
- Severe pulmonary laceration or tracheobronchial injury.
- Esophageal rupture.
- Combined thoracoabdominal or abdominothoracic injuries.
- Large chest wall defects.
- Retained large foreign bodies in the thoracic cavity.
Emergency Room Thoracotomy
Advances in pre-hospital care have increased the likelihood of severely injured thoracic trauma patients being transported to hospitals. Upon arrival at the emergency room, patients in a pre-terminal state may exhibit loss of consciousness, gasping respirations, weak pulse, or even unmeasurable blood pressure, but with the presence of electrocardiographic activity. Those in profound shock may retain consciousness but present with an arterial systolic blood pressure less than 80 mmHg. For these critically injured patients, the most urgent interventions are required to maximize the chance of survival. Emergency room thoracotomy (ERT) serves as an immediate rescue measure to avoid delays associated with in-hospital transport.
ERT is indicated in the following scenarios:
- Severe shock caused by penetrating thoracic injuries.
- Pre-terminal patients with penetrating thoracic injuries where acute cardiac tamponade is highly suspected.
The procedure is performed under endotracheal intubation via a rapid anterolateral thoracotomy at the fourth or fifth intercostal space. Critical measures for successful surgical rescue include prompt relief of cardiac tamponade, effective hemorrhage control, and rapid blood volume replacement.