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:
- Additional Resources:
- Occult penetrating cardiac injuries: Ramiro Manzano-Nunez, MD; Alexandra Gomez, MD; et al. 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. J Trauma Acute Care Surg. 2021
- 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;259(3):438-42.
- Pericardial drainage for occult cardiac injury: Chad M. Thorson, MD; Nicholas Namias, MD; et al. Does hemopericardium after chest trauma mandate sternotomy? J Trauma Acute Care Surg 2012.
- El-Andari R, O’Brien D, Bozso SJ, et al. Blunt cardiac trauma: a narrative review. Mediastinum. 2021;5:28.
- Ali Salim, MD; George C. Velmahos, MD; et al. Clinically Significant Blunt Cardiac Trauma: Role of Serum Troponin Levels Combined with Electrocardiographic Findings. J Trauma Acute Care Surg 2001.
- Diagnostic testing: Keith Clancy, MD; Catherine Velopulos, MD; et al. Screening for blunt cardiac injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 2012.
- 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;18(1):36.
- 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. Resuscitative thoracotomy following wartime injury. J Trauma 2013
- 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. An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma. Journal of Trauma and Acute Care Surgery 2015.
- Ernest E. Moore, MD; M. Margaret Knudson, MD; et al. Defining the limits of resuscitative emergency department thoracotomy: a contemporary Western Trauma Association perspective. J Trauma 2011.
- 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
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
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. Airway management following repair of cervical tracheal injuries: a retrospective, multicenter study. J Trauma Acute Care Surg 2016.
- 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. Thoracotomy for emergency repair of iatrogenic tracheal rupture: single center analysis of perioperative management and outcomes. BMC Anesthesiology 2019.
- Harpereet Singh Grewal, MD; Neha S. Dangayach, MD; et al. Treatment of tracheobronchial injuries: A contemporary review. Chest 2019.
- Joanna B. Moser, MBChB, FRCR; Konstantinos Stefanidis, MD, PhD; and Ioannis Vlahos, MBBS, MRCP, FRCR. Imaging evaluation of tracheobronchial injuries. RadioGraphics 2020.
- Stefan Welter and Weam Essaleh. Management of tracheobronchial injuries. J Thor Dis 2020.
- Anna Rieth, Endre Varga, et al. Contemporary management strategies of blunt tracheobronchial injuries. Injury 2021.
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