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Thoracic Emergencies

Introduction

General Approach

• Damage-control resuscitation (DCR): early haemorrhage control, balanced blood-product replacement (whole blood or 1: 1: 1), permissive hypotension until bleeding is controlled, tranexamic acid within 3 h, active prevention/correction of hypothermia, acidosis, and coagulopathy.
• Airway
  • Videolaryngoscopy (VL) is now first-line for rapid sequence induction (RSI); it improves first-pass success and reduces hypoxaemia compared with direct laryngoscopy.
  • Maintain in-line cervical stabilisation. Pre-oxygenate head-up with positive pressure or high-flow nasal cannula (HFNC) when possible.
  • Suspect tension pneumothorax as the commonest reversible cause of sudden deterioration post-intubation; treat empirically.
  • Lung isolation is rarely required immediately; if necessary, prefer single-lumen tube + bronchial blocker or left-sided double-lumen tube placed under bronchoscopic guidance.
• Monitoring: large-bore IV access, arterial line, point-of-care visco-elastic testing, transthoracic/oesophageal echo where expertise exists. BIS adds little in unstable trauma and is not recommended.

Pulmonary Contusion

Pathophysiology

Blunt chest trauma leads to parenchymal haemorrhage, interstitial oedema, loss of surfactant and alveolar collapse, producing ventilation–perfusion mismatch, shunt, and decreased compliance. Incidence ≈ 30 %; contemporary mortality 8-15 %.

Diagnosis

• CT is more sensitive than plain radiography and quantifies contusion size; radiographic changes may lag 6–12 h.

Management

• Escalating respiratory support: HFNC, non-invasive ventilation (NIV), invasive ventilation with low VT (6 ml kg⁻¹ PBW), adequate PEEP, permissive hypercapnia, and prone positioning when indicated. Early HFNC can improve oxygenation and delay intubation in moderate hypoxaemia.
• Analgesia is critical. Thoracic epidural analgesia (TEA) remains gold standard for severe injury, but modern alternatives such as erector spinae plane block (ESPB) or paravertebral block (PVB) provide comparable pain relief with fewer contraindications.
• Surgical rib fixation should be considered in flail chest that fails non-operative management or delays ventilator weaning.
• EAST 2020 guideline discourages steroids or prophylactic diuretics; fluid therapy should be judicious.

Systemic Air Embolism

Suspect with cardiovascular collapse, neurological change or haemoptysis after positive-pressure ventilation. Minimise airway pressures, place injured lung down, resuscitate, and consider thoracotomy with hilar clamp

Tracheo-bronchial Injury

• 75 % occur within 2.5 cm of the carina.
• Maintain spontaneous ventilation; intubate over bronchoscope with cuff distal to tear. Rigid bronchoscopy or ECMO/femoro-femoral bypass may be life-saving in extensive disruption
• Avoid jet ventilation or LMA PPV. If airway fails, proceed to surgical control.

Haemothorax

• Insert a large-bore intercostal catheter (ICC) early; > 1500 ml immediate return or > 200 ml h⁻¹ for 3 h mandates thoracotomy.
• Video-assisted thoracoscopic surgery (VATS) is effective for retained/ongoing bleeding in stable patients.

Diaphragmatic Injury

• Multidetector CT with multiplanar reconstruction is the non-invasive gold standard; pooled sensitivity ~ 80 %, specificity > 90 %.
• VATS/laparoscopy offer > 95 % diagnostic accuracy and allow definitive repair.

Cardiac Contusion

• Combine 12-lead ECG and high-sensitivity troponin at admission: if both normal, significant blunt cardiac injury is very unlikely and prolonged monitoring is unnecessary.
• Abnormal ECG or troponin warrants continuous monitoring 24-48 h and echocardiography if instability develops.
• Delay elective surgery 24-48 h after significant injury; consider intra-aortic balloon pump for cardiogenic shock unresponsive to medical therapy.

Aortic Injury

• Blunt thoracic aortic injury (BTAI) is the second leading cause of death after head injury in high-speed deceleration trauma. Most survivors have an intact adventitia or contained pseudo-aneurysm at the isthmus.
• Diagnosis: contrast-enhanced chest CT is first-line; TEE is adjunct in the haemodynamically unstable.
• Management: thoracic endovascular aortic repair (TEVAR) is preferred over open repair owing to lower mortality and paraplegia. Blood-pressure control with intravenous β-blockade (target SBP < 120 mm Hg, HR < 90) is essential until repair.
• Timing: urgent repair within 24 h once other life-threatening injuries are stabilised. Selected grade II injuries with meticulous medical therapy may be delayed safely.
• Anaesthetic considerations: prepare for remote-site anaesthesia (radiology suite or hybrid theatre); invasive monitoring, large-bore access, availability of TEE, and spinal cord protection strategies (MAP > 80 mm Hg post-stent) are mandatory.

Links

• One lung Ventilation and VATS
• Anaesthesia emergencies
• Aortic surgery
• Endovascular Abdominal Aortic Aneurysm Repair (EVAR)
• Vascular surgery
• Cardiac surgery

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References

1. Joint Trauma System Clinical Practice Guideline. Damage Control Resuscitation. 2023.
2. Driver BE, et al. Video versus direct laryngoscopy for tracheal intubation of critically ill adults. N Engl J Med. 2023;389:1961-1973.
3. Eastern Association for the Surgery of Trauma. Practice management guideline: Pulmonary contusion and flail chest (update). 2020.
4. Gupta R, et al. Early high-flow nasal cannula in post-traumatic pulmonary contusion: randomised clinical trial. Indian J Crit Care Med. 2025;29:110-117.
5. Clifford R, Ventham N. Management of blunt thoracic trauma. BJA Educ. 2022;22:100-109
6. Abdelrahman A, et al. Ultrasound-guided erector spinae plane block vs thoracic epidural in traumatic flail chest: a prospective RCT. J Anaesthesiol Clin Pharmacol. 2023;39:321-327.
7. Kulakowski E, et al. Regional analgesia modalities in blunt thoracic trauma: systematic review and Bayesian network meta-analysis. Am J Emerg Med. 2024;68:89-96.
8. StatPearls Publishing. Tracheobronchial Tear. 2023.
9. Agarwal S, et al. Traumatic injuries to the trachea and bronchi: narrative review. Med Sci Monit. 2024;30:e940112.
10. The Calgary Guide to Understanding Disease. (2024). Retrieved June 5, 2024, from https://calgaryguide.ucalgary.ca/
11. FRCA Mind Maps. (2024). Retrieved June 5, 2024, from https://www.frcamindmaps.org/
12. Anesthesia Considerations. (2024). Retrieved June 5, 2024, from https://www.anesthesiaconsiderations.com/
13. ICU One Pager. (2024). Retrieved June 5, 2024, from https://onepagericu.com/

Summaries:
Cardiothoracic trauma anaesthesia- video
Cardiothoracic trauma-video

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© 2025 Francois Uys. All Rights Reserved.

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