What is Chest Trauma and Emergency Surgery? In Which Cases Is It Performed?

Chest traumas can present in a wide range, from a simple rib crack to life-threatening internal organ injuries. Since the heart, lungs, and major vessels are located in this region, they are responsible for a significant portion of trauma-related deaths. However, the good news is that 85-90% of chest traumas can be successfully treated simply by inserting a chest tube.

In this article, you will find answers to questions such as what chest trauma is, what complications it leads to, how it is diagnosed, and when emergency chest trauma surgery is required.

What is Chest Trauma and Its Types?

Chest traumas account for approximately 25% of trauma-related deaths. Defined as the disruption of the anatomical and functional integrity of the structures forming the rib cage, these injuries are divided into two main categories: blunt and penetrating traumas. Thoracic traumas consist of 70% blunt and 30% penetrating injuries.

The type of injury directly affects the treatment approach and the need for emergency intervention. Patients mostly consist of men aged 25-50, and findings such as flank pain, shortness of breath, and subcutaneous emphysema appear after the trauma.

Blunt Chest Traumas

Blunt traumas occur as a result of high-energy impacts to the rib cage without disrupting the integrity of the skin. They may not look serious from the outside, but internal organ damage can develop inside.

Traffic accidents are the most common cause of blunt traumas. In addition, falls from heights, assault incidents, impacts with hard objects, and crushing situations also fall into this group. Blunt trauma causes injury through three different mechanisms: pressure, rupture, and blast.

Sudden compression of the rib cage increases intrathoracic pressure and leads to organ damage. Sudden deceleration creates a tearing effect on vascular structures. Rib fractures are present in 35-40% of blunt traumas. The most frequently fractured ribs are between the 4th and 9th ribs, and lung, pleural, bronchial, and cardiac injuries can be seen with these fractures.

If there is a fracture in the first rib, it means there is a serious associated injury. Since this rib is protected by strong muscles and bones, its fracture requires great force.

Piercing and Cutting Chest Injuries

Penetrating traumas occur as a result of stab wound injuries and firearm injuries. The integrity of the chest wall is disrupted, and air from the external environment can fill the lung cavity.

In this type of trauma, a channel is opened between the outside world and the chest cavity. An open wound or puncture is seen on the skin, which can cause the lungs to collapse suddenly. The path followed by the injury channel can affect critical structures such as the heart, esophagus, or major vessels.

In firearm injuries, the barrel length of the bullet and the shooting distance determine the degree of damage. In piercing and cutting instrument injuries, internal organ damage must be examined carefully. The risk of infection increases in open wounds, and bleeding is more prominent.

Factors Determining Trauma Severity

The severity of the trauma depends on several factors. The angle of impact, intensity, and characteristics of the injuring object determine the extent of the injury.

The number of rib fractures has a significant effect on mortality and morbidity. In patients with three or more rib fractures, the risk of complications such as pulmonary contusion and pneumonia increases, even if the fracture is isolated. Seven or more rib fractures increase the mortality rate up to 29%.

The type of organ affected by the trauma is also of critical importance. Heart, major vessel, lung, and diaphragm injuries carry a higher risk. It should be kept in mind that those who have had a traffic accident may have multiple system injuries. The patient's age and pre-existing chronic lung diseases are also among the factors affecting the outcome.

Complications Seen in Chest Traumas

Complications that occur after thoracic trauma can rapidly disrupt the patient's respiratory and circulatory balance. Similar clinical pictures develop in both blunt and penetrating injuries. While late-stage complications are seen in 15% of trauma patients, early intervention can reduce this rate.

Pneumothorax (Lung Collapse)

The accumulation of air between the lung membranes is called pneumothorax. This condition causes the lung to shrink and fail to perform its function, creating severe shortness of breath. Sudden chest pain and respiratory difficulty are its most prominent symptoms.

Pneumothorax occurs in different ways. In simple pneumothorax, air accumulation is limited and can heal spontaneously. However, in tension pneumothorax, air can enter the pleural space but cannot get out. This creates pressure inside the chest, puts pressure on the heart, and carries a vital risk.

In treatment, a chest tube is inserted to remove the accumulated air. This treatment is usually sufficient for patients. However, surgical intervention may be required in recurrent cases.

Hemothorax (Blood Accumulation in the Chest Cavity)

The accumulation of more than 250 mL of blood in the chest cavity is considered hemothorax. Chest injury and trauma are the most common causes. In rib fractures, the damage caused by the fractured ends on the lung and intercostal vessels results in bleeding.

Hemothorax is classified according to the amount. 400 mL and below is called minimal, between 400-1500 mL moderate, and above 1500 mL massive hemothorax. Bleeding above 1500 mL or blood loss exceeding 200 mL per hour requires emergency surgery.

Shortness of breath, chest pain, increased heart rate, and decreased blood pressure are typical symptoms. In treatment, accumulated blood is evacuated with a chest tube. If the bleeding cannot be stopped, a thoracotomy is performed to bring the source under control.

Flail Chest and Respiratory Problems

As a result of the fracture of three or more ribs from at least two places, a section of the chest wall moves independently. This condition is called flail chest. It is seen in 5-15% of chest traumas, and the mortality rate is 10-15%.

When breathing in, the fractured area collapses inward; when breathing out, it comes outward. This paradoxical movement makes breathing difficult. It is usually the result of very severe blunt traumas and requires intensive care support. If the respiratory rate is more than 35, mechanical ventilation is applied.

Pulmonary Contusion

It is the bruising of the lung tissue due to trauma and the formation of bleeding within it. Pulmonary contusion develops in 25-35% of patients who receive major trauma to the chest wall. It accompanies approximately 30-75% of severe blunt thoracic traumas.

Symptoms may not appear immediately after the trauma. Gradual deterioration is seen within the first 24-48 hours. Chest pain, shortness of breath, and bloody sputum are typical findings. Even if there is no rib fracture, the lung may not be able to perform gas exchange due to contusion alone.

Rib Fractures and Their Effects

Rib fractures are the most common consequence of chest traumas. Severe pain developing on the fractured side, especially with breathing, is the most important symptom. The patient has difficulty breathing due to intense pain, cannot lie down, and tries to suppress their cough.

The sharp ends of the fractured ribs can pierce the lung, causing bleeding and lung collapse. As the number of fractures increases, the risk of complications rises. Early-stage complications are hemothorax and pneumothorax, while late-stage complications are atelectasis and pneumonia. The most common late complication in blunt traumas is pneumonia at a rate of 41.07%.

Chest Trauma Diagnosis and Evaluation Methods

Time is of vital importance in trauma patients, so the diagnostic process must be carried out quickly and in an organized manner. Thanks to correct diagnostic methods, life-threatening conditions are detected at an early stage, and intervention is not delayed.

Physical Examination and Initial Assessment

The first step in chest traumas is physical examination. The doctor checks the patient's chest area and examines swelling, bruising, and pain points. It is carefully listened to whether the breath sounds are equal. If the sound decreases on one side, pneumothorax or hemothorax is suspected.

The presence of subcutaneous emphysema and the presence of flail chest are prominent findings in the physical examination. Heartbeats and pulse rhythm are evaluated. Ensuring airway clearance and supporting breathing is the golden rule. This initial assessment can be done without any equipment, but it may not fully show internal organ injuries.

Chest X-Ray and Thoracic CT

Chest X-ray is the first and most valuable diagnostic tool after thoracic trauma. It is available in every health center, and results can be evaluated quickly. However, it can miss many rib fractures or small-scale bleedings. Diagnosis is reached with chest X-ray in 58.2% of patients.

Thoracic CT is the most reliable tool in mapping the injury and detecting vital vascular damage. It helps to reveal pathologies that cannot be determined on a chest X-ray. It provides more detailed examination of complex injuries, especially. It must be used in major vessel, heart, and mediastinal injuries.

The radiation dose received in a thoracic CT scan corresponds to approximately 150-200 chest X-rays. Therefore, it is preferred when necessary, but it is not routinely applied to every patient.

FAST Ultrasonography

FAST ultrasonography used in emergency departments shows whether fluid has accumulated in the chest or abdominal cavity in seconds. This method provides great speed in deciding whether the patient will be taken to the operating room or intensive care.

FAST ultrasonography does not contain radiation and can be performed at the bedside. It is superior to chest X-ray in detecting hemothorax. While 200 cc of fluid is required on the X-ray for hemothorax, 20 cc of fluid can be detected on ultrasonography. The sensitivity of ultrasonography in detecting pneumothorax is between 78.6-100%.

When FAST and chest X-ray are compared in the diagnosis of hemothorax, the sensitivity was found to be 97.5% for ultrasonography and 92.5% for chest X-ray. It is among the imaging methods to be preferred first in hemodynamically unstable patients.

Emergency Chest Trauma Surgery: Treatment Options

Chest trauma surgery is performed to stop bleeding and protect organ functions. The vast majority of traumas are successfully treated with non-surgical methods. When surgical intervention is required, several different techniques are applied.

Tube Thoracostomy (Chest Tube)

Insertion of a chest tube is a life-saving procedure in emergency situations. 85-90% of chest traumas can be successfully treated simply by inserting a chest tube. The primary goal is to ensure the evacuation of air or fluid in the pleural space.

The most common indication for tube thoracostomy in trauma patients is pneumothorax. During the procedure, a flexible tube is placed into the pleural space through the intercostal spaces. It is understood that the tube is inside the thorax by drainage or the up-and-down movement of the liquid in the drainage bottle during respiration.

Small-diameter (16-24 F) silicone tubes directed to the apex are sufficient in patients with pneumothorax. When the diagnosis of hemothorax is confirmed, the thickest possible tube (32-36 F) should be applied. In hemothorax, tube thoracostomy is used not only for drainage but also for monitoring purposes.

When performed with the appropriate indication, it provides a dramatic improvement in the symptoms of acute illness. Bleeding stops when the lung expands in 58% of cases. The complication development rate in tube thoracostomy has been reported as 9%-21%.

Plate Fixation in Rib Fractures

Chest wall plates are used to stabilize and support fractured bones. These implants provide support and stability during the healing process, minimizing pain and facilitating faster healing.

Plate fixation comes to the agenda in patients who develop three or more fractures or flail chest. The fractured ends are brought into their anatomical positions and fixed with titanium plates and screws. The integrity of the chest wall and respiratory mechanics are re-established.

Plates are typically made of materials such as stainless steel or titanium. They are specially designed to fit the contour and anatomy of the chest wall. The procedure is performed under general anesthesia and takes about 2-3 hours.

Early mobilization is encouraged after surgery. Chest physiotherapy and respiratory exercises are of critical importance in terms of reducing the risk of pneumonia. This approach reduces both the patient's intensive care duration and hospital stay days.

Emergency Thoracotomy and VATS Method

Thoracotomy is a complex surgical procedure in which the rib cage is opened. It is a method that allows direct intervention in the chest cavity. In emergency situations such as aortic rupture, the chest can be opened and the aorta can be repaired.

After thoracotomy surgery, the patient stays in the hospital for about 5-7 days. During the procedure, a chest tube is placed to evacuate excess fluid or air leaking into the chest.

VATS is a minimally invasive surgical method. Compared to traditional thoracotomy, it offers a less painful recovery process and shortens the hospital stay. Thanks to high-resolution imaging technology, surgeons can perform more precise interventions.

VATS can be performed in patients with thoracic trauma, and hemothorax constitutes the most common surgical indication. However, VATS is not recommended if the patient has hemodynamic instability in massive hemothorax.

In Which Cases Is Surgery Required?

If there is 1500 cc or more drainage after tube insertion, surgery is required. It is necessary to perform a thoracotomy if there is bleeding of 200 cc or more per hour for 4 hours, or 100 cc or more per hour in 8 hours of follow-up.

In massive hemothorax cases, hemorrhage status of more than 1500 mL upon admission or more than 200 mL per hour during four hours of follow-up is a surgical indication. Surgical fixation is performed when fractured fragments threaten the lung and cause bleeding.

Frequently Asked Questions

If you have shortness of breath starting immediately after the impact or within hours, blood coming with cough, stabbing pain when breathing, and bruising on the chest, you should apply without wasting time. Individuals who develop chest pain, rapid breathing, coughing up blood, subcutaneous emphysema, open chest wound, change in consciousness, or low blood pressure should apply to the emergency department without delay.

All patients experiencing high-energy trauma should receive a comprehensive evaluation for chest injury. In elderly individuals, cases with chest pain, shortness of breath, or rib tenderness even after a simple fall must be evaluated. Especially patients using blood thinners should be monitored carefully even after minor trauma.

It is recommended that you apply to the emergency department without waiting for a check-up in situations such as a sudden increase in shortness of breath and a sharp rise in pain.

Ribs usually heal on their own within 4-8 weeks. The vast majority of rib fractures heal without requiring surgical intervention. Patients are usually treated on an outpatient basis and called for check-ups, and the most important treatment is to keep the pain under appropriate control.

However, surgery may be required in some cases. If respiratory movements are impaired as a result of the fracture of three or more ribs in two or more places, surgical intervention may be required. In surgical treatment, plates and screws are applied to the ribs to ensure the stability of the rib cage.

The decision for surgery is made by evaluating the patient's respiratory function, number of fractures, and general condition together. Surgery may be required in flail chest, presence of an open wound, intolerable pain, and displaced rib fractures. Therefore, not every rib fracture requires surgery.

Early mobilization is encouraged after surgery. Breathing exercises and early walking are of vital importance to prevent lung collapse. The hospital stay is usually 5-7 days.

The most important element after surgery is pain management. Chest physiotherapy and respiratory exercises are of critical importance in reducing the risk of lung inflammation in the postoperative period. Patients who receive surgical treatment must follow regular follow-ups and consult a physician in case of respiratory distress, fever, change in sputum, or increased pain.

If rib fractures have not damaged the lung, they heal in at least 4 to 6 weeks, depending on the patient's condition, with the bone ends coming end-to-end. However, healing of the fracture is delayed, especially in people who move a lot, smoke, and cough frequently. Complete recovery may take up to 6 months in patients with accompanying lung damage.

Lung collapse is a condition that requires emergency intervention as it can pose a life risk. Especially in the case of complete collapse of the lung or rapid increase in air accumulation, it can pose a life threat. Its most dangerous form is tension pneumothorax and can lead to sudden death.

Lung collapse that occurs suddenly in both lungs can be fatal. Lung collapse can lead to a life risk depending on the size of the collapse, the rate of progression, and the heart problems it causes.

In small and stable cases, close monitoring, rest, and oxygen support are often sufficient. Small-scale collapses can improve with oxygen therapy and observation, but a chest tube must be inserted for collapses above a certain level. Lung collapse is a condition that can be brought under control if intervened at the right time, but it creates a vital danger when neglected.

In Summary: Chest Trauma and Emergency Surgery

Although chest traumas look frightening at first glance, they can be successfully treated to a large extent when intervened at the right time. It must be strongly emphasized that the vast majority of these injuries heal simply by inserting a chest tube and do not require surgery.

If you are experiencing symptoms such as shortness of breath, severe pain in the chest, or coughing up blood, you should apply to the emergency department without wasting time. Early diagnosis saves lives and prevents complications.

Every person who receives a blow to the chest area must be evaluated. Your doctor will determine the treatment method most appropriate for your condition and guide you through your recovery process.

Fill Out the Form for Detailed Information and Contact!