Thoracic Trauma

Cardiac Injuries

The fellow should be able to:

Demonstrate an understanding of the pathophysiology of blunt cardiac injury
Understand the diagnosis and treatment approach to BCI
Describe the evaluation for patients presenting with penetrating injuries to the thorax
Recognize the limitations and controversies as related to the concept of the “cardiac box”
Describe the role and limitations of ultrasound and pericardial window in the diagnosis of cardiac injury
Describe surgical techniques for treatment of cardiac injury
Describe techniques for managing an open chest
Understand post-operative management after repair of cardiac injury

Resources

Topic Summary
AAST Education Module - Penetrating Cardiac Injuries
AAST Education Module - Blunt Cardiac Injury
AAST Education Module - Cardiac Tamponade
Meet the Mentors - Penetrating Cardiac Injuries
Meet the Mentors- Penetrating Cardiac Injury: How to Mend a Broken Heart
Meet the Mentors- Penetrating Mediastinal Trauma
Overview Articles:
- Hromalik LR, Wall MJ, Mattox KL, et al. Penetrating cardiac injury: a narrative review. Mediastinum. 2023;7:15.
- Walter L. Bliff, MD; Jason A. Fawley, MD and Rajeev C. Mohan, MD., J Trauma Acute Care Surg 2023. Diagnosis and Management of Blunt Cardiac Injury: What You Need to Know
Additional Resources:
- Occult penetrating cardiac injuries: Ramiro Manzano-Nunez, MD; Alexandra Gomez, MD; et al., J Trauma Acute Care Surg. 2021 A meta-analysis of the diagnostic accuracy of chest ultrasound for the diagnosis of occult penetrating cardiac injuries in hemodynamically stable patients with penetrating thoracic trauma
- Pericardial drainage for occult cardiac injury: Nicol AJ, Navsaria PH, Hommes M, et al. Sternotomy or Drainage for a Hemopericardium After Penetrating Trauma: A randomized Controlled Trial. Ann Surg. 2014.
- Pericardial drainage for occult cardiac injury: Chad M. Thorson, MD; Nicholas Namias, MD; et al., J Trauma Acute Care Surg 2012. Does hemopericardium after chest trauma mandate sternotomy
- El-Andari R, O’Brien D, Bozso SJ, et al. Blunt cardiac trauma: a narrative review. Mediastinum. 2021.
- Ali Salim, MD; George C. Velmahos, MD; et al., J Trauma Acute Care Surg 2001. Clinically Significant Blunt Cardiac Trauma: Role of Serum Troponin Levels Combined with Electrocardiographic Findings
- Diagnostic testing: Keith Clancy, MD; Catherine Velopulos, MD; et al., J Trauma Acute Care Surg 2012. Screening for blunt cardiac injury: an Eastern Association for the Surgery of Trauma practice management guideline
- Diagnostic testing: Kyriazidis IP, Jakob DA, Vargas JAH, et al. Accuracy of diagnostic tests in cardiac injury after blunt chest trauma: a systematic review and meta-analysis. World J Emerg Surg. 2023.
- Operative Technique: Demetriades D, Inaba K, Velmahos G. Atlas of Surgical Techniques in Trauma. Chapter 15: Cardiac Injuries. Cambridges University Press, 2015.

Traumatic Cardiac Arrest

The fellow should be able to:

Demonstrate an understanding of etiology of traumatic cardiac arrest and treatment of each
Understand the controversies within the field regarding the treatment of TCA
Identify patients most likely to benefit from resuscitative thoracotomy
Understand the differences between the EAST and WTA guidelines and limitations of each guideline
Describe the role of ultrasound in TCA, including how to identify tamponade and recognize cardiac standstill on ultrasound
Describe the steps of resuscitative thoracotomy and when to convert to clamshell thoracotomy

Resources

Topic Summary
Overview Article:
- Smith JE, Rickard A, Wise D. Traumatic Cardiac Arrest. J R Soc Med. 2015 Jan;108(1):11-6.
Additional Resources
- Jonathan J. Morrison, MRCS; Henrietta Poon, MRCS; et al., J Trauma 2013. Resuscitative thoracotomy following wartime injury
- Wongtanasarasin W, Thepchinda T, Kasirawat C, Saetiao S, Leungvorawat J, Kittivorakanchai N. Treatment Outcomes of Epinephrine for Traumatic Out-of-hospital Cardiac Arrest: A Systematic Review and Meta-analysis. J Emerg Trauma Shock. 2021 Oct-Dec;14(4):195-200
- Lewis J, Perkins GD. Traumatic cardiac arrest. Curr Opin Crit Care. 2023 Jun 1;29(3):162-167
- Mark J. Seamon, MD; Elliott R. Haut, MD; et al., Journal of Trauma and Acute Care Surgery 2015. An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma
- Ernest E. Moore, MD; M. Margaret Knudson, MD; et al., J Trauma 2011. Defining the limits of resuscitative emergency department thoracotomy: a contemporary Western Trauma Association perspective
- Cralley AL, Vigneshwar N, Moore EE, Dubose J, Brenner ML, Sauaia A; AAST AORTA Study Group. Zone 1 Endovascular Balloon Occlusion of the Aorta vs Resuscitative Thoracotomy for Patient Resuscitation After Severe Hemorrhagic Shock. JAMA Surg. 2023;158(2):140-150

Chest Wall Injury and Rib Fractures

The fellow should be able to:

Demonstrate an understanding how to evaluate a patient presenting with thoracic trauma including the limitations of physical exam and indications/limitations of imaging
Describe the role of routine thoracic CT scanning vs selective thoracic CT scanning
Describe the role of screening criteria and differences in criteria between systems
Demonstrate an understanding of how rib fractures alter a patient’s respiratory mechanics and lead to pulmonary complications
Describe treatment strategies designed to mitigate the consequences of rib fractures
Discuss the prognostic tools that have been developed to risk stratify patients with rib fractures
Describe the role of rib fracture fixation, indications for rib fixation, and controversies associated with operative management of rib fractures
Discuss different options for rib fracture fixation and outcomes
Describe the management of sternal fractures including indications for operative repair and controversies surrounding operative repair

Resources

Topic Summary
AAST Education Module - Sternal Fractures
AAST Education Module - Surgical Stabilization of Rib Fractures
AAST Education Module - Rib Fractures
Meet the Mentors - Evidence-Based Approach to Surgical Stabilization of Rib Fractures in 2021 and Beyond
EAST Guidelines - Non-Surgical Management and Analgesia Strategies for Older Adults with Multiple Rib Fractures: a Systematic Review, Meta-Analysis, and Practice Management Guideline
EAST Guidelines - Open Reduction and Internal Fixation of Rib Fractures

Hemothorax and Pneumothorax

The fellow should be able to:

Demonstrate an understanding how hemothorax/pneumothorax management is evolving including the criteria for observation vs routine chest tube placement
Describe the role for small bore vs large bore chest tubes in the management of hemothorax and pneumothorax
Describe indications for immediate operative intervention in the setting of massive hemothorax
Describe the strategies utilized to prevent retained hemothorax
Describe the treatment options for persistent air leak, retained hemothorax, and empyema

Resources

Topic Summary
AAST Education Module - Massive Hemothorax
AAST Education Module - Persistent Pneumothorax
AAST Education Module - Retained Hemothorax
AAST Education Module - Open Pneumothorax
May 2024 Journal Club - Traumatic Hemothorax Chest Tube Size
Overview Article:
- Jeff Choi, MD, MSc; Joshua Villarreal, MD; et al., Surgery 2022 Scoping Review of Traumatic Hemothorax
Additional Resources
- K. Robert Shen, MD; Alejandro Bribriesco, MD; et al., J Thorac Cardiovasc Surg, 2017 AATS Consensus Guideline for Management of Empyema
- Nimitt J. Patel, Linda Dultz, et al., Am J Surg 2021. Management of simple and retained hemothorax: A practice management guideline from the Eastern Association for the Surgery of Trauma
- George Beeton, BS; Micah Ngatuvai, MBA; et al., Am Surgeon 2023. Outcomes of Pigtail Catheter Placement versus Chest Tube Placement in Adult Thoracic Trauma Patients: A Systematic Review and Meta-Analysis
EAST Guidelines
- Jennifer J. Freeman, Sofya H. Asfaw, et al. Antibiotic prophylaxis for tube thoracostomy placement in trauma. Trauma Surg Acute Care Open 2022.

Pulmonary Injury

The fellow should be able to:

Demonstrate an understanding of the management of tracheobronchial injury including the management of massive air leaks and hemoptysis
Describe the operative management options for pulmonary injuries
Describe the management of tracheobronchial injury
Understand the consequences of pneumonectomy in trauma and how to mitigate these complications

Resources

Topic Summary
AAST Education Module - Pulmonary Parenchymal Injuries
AAST Education Module - Tracheobronchial Injuries
AAST Education Module - Pneumatocele
Meet the Mentors - Thoracic Injuries: Tips & Tricks
Additional Resources:
- Lyons JD, Feliciano DV, Wyrzykowski AD, Rozycki GS. Modern management of penetrating tracheal injuries. Am Surg 2013; 79: 188-193.
- Madani A, Pecorelli N, Razek T, et al. Civilian airway trauma: a single-institution experience. World J Surg 2016; 40: 2658-2666.
- John A. Harvin, MD; Ethan A. Taub, DO; et al., J Trauma Acute Care Surg 2016. Airway management following repair of cervical tracheal injuries: a retrospective, multicenter study
- Kiser AC, O’Brien SM, Detterbeck FC. Blunt tracheobronchial injuries: treatment and outcomes. Ann Thorac Surg 2001; 71: 2059-2065. Modern References
- Manuel F. Struck, Gunther Hempel, et al., BMC Anesthesiology 2019. Thoracotomy for emergency repair of iatrogenic tracheal rupture: single center analysis of perioperative management and outcomes
- Harpereet Singh Grewal, MD; Neha S. Dangayach, MD; et al., Chest 2019. Treatment of tracheobronchial injuries: A contemporary review
- Joanna B. Moser, MBChB, FRCR; Konstantinos Stefanidis, MD, PhD; and Ioannis Vlahos, MBBS, MRCP, FRCR., RadioGraphics 2020. Imaging evaluation of tracheobronchial injuries
- Stefan Welter and Weam Essaleh., J Thor Dis 2020. Management of tracheobronchial injuries
- Anna Rieth, Endre Varga, et al., Injury 2021. Contemporary management strategies of blunt tracheobronchial injuries

Great Vessel Injury

The fellow should be able to:

Demonstrate an understanding of the evaluation of a widened mediastinum on chest x-ray
Understand the classification and treatment of blunt aortic injuries including considerations for competing injury priorities
Describe the techniques and complications of open and endovascular repair for blunt aortic injury
Describe techniques for exposure and repair of penetrating injuries of the thoracic and abdominal aorta
Describe techniques for exposure and repair of innominate injuries

Resources

Topic Summary
AAST Education Module - Innominate Artery Injuries
AAST Education Module - Blunt Traumatic Aortic Injuries
AAST Education Module - Ascending Aortic Injuries
Meet the Mentors - Thoracic Great Vessel Injury
Meet the Mentors - Injuries to the Aorta and Its Branches
EAST Guidelines
- Evaluation and Management of Blunt Aortic Injury