Version May 2024
INTRODUCTION — Blunt or penetrating thoracic trauma can cause major injuries including myocardial or vascular injury (eg, aorta, pulmonary vessels), cardiac tamponade, tracheobronchial injury, pulmonary contusion, pneumothorax or hemothorax, esophageal injury, or chest wall injuries, such as rib fractures and flail chest. Initial evaluation and management of these life-threatening injuries are discussed in separate topics:
●(See "Initial evaluation and management of blunt thoracic trauma in adults".)
●(See "Initial evaluation and management of penetrating thoracic trauma in adults".)
●(See "Initial evaluation and management of chest wall trauma in adults".)
This topic will review anesthetic management of patients with traumatic injuries to intrathoracic structures and/or the chest wall. Anesthetic considerations that are generally applicable for all trauma patients are discussed in separate topics. (See "Anesthesia for adult trauma patients" and "Overview of blunt and penetrating thoracic vascular injury in adults" and "Management of cardiac injury in severely injured patients" and "Pulmonary contusion in adults" and "Management of blunt thoracic aortic injury" and "Overview of esophageal injury due to blunt or penetrating trauma in adults".)
INITIAL APPROACH
General considerations — Initial resuscitation and management strategies for thoracic trauma patients are based on Advanced Trauma Life Support (ATLS) protocols that emphasize assessing and stabilizing the patient's airway, breathing, and circulation (ie, ABCs), in that order (algorithm 1). In particular, life-threatening issues such as airway obstruction, cardiac tamponade, tension pneumothorax, massive hemothorax, and flail chest require emergency interventions. In some patients with respiratory distress following chest trauma, breathing may take priority over airway (eg, a tension pneumothorax should be treated before performing endotracheal intubation since pressure ventilation following intubation will exacerbate a pneumothorax) (see 'Pneumothorax' below). Other potentially lethal injuries that may not be easily recognized on initial physical examination include simple pneumothorax, hemothorax, pulmonary contusion, cardiac contusion, tracheobronchial injury, diaphragmatic injury, esophageal rupture, or contained aortic disruption.
Details regarding mechanisms of injury after blunt or penetrating trauma are discussed separately. (See "Initial evaluation and management of blunt thoracic trauma in adults", section on 'Anatomy and Injury Patterns' and "Initial evaluation and management of penetrating thoracic trauma in adults", section on 'Anatomy and mechanism'.)
Unstable patients
Traumatic airway injury or obstruction — The American Society of Anesthesiologists Committee on Trauma and Emergency Preparedness has developed guidance for the anesthesiologist managing a difficult airway in patients with traumatic airway injury or obstruction (algorithm 2). (See "Identification and management of tracheobronchial injuries due to blunt or penetrating trauma".)
Further details regarding emergency airway management in trauma patients are available in other topics:
●(See "Overview of advanced airway management in adults for emergency medicine and critical care".)
●(See "Airway management in the adult with direct airway trauma for emergency medicine and critical care".)
●(See "Anesthesia for adult trauma patients", section on 'Airway management'.)
●(See "Management of the difficult airway for general anesthesia in adults".)
Hemodynamic instability — If feasible, emergency ultrasonography (focused assessment with sonography for trauma [FAST]) is performed in a hemodynamically unstable patient to assess the nature and extent of the injures, including assessment of the pericardium to look for hemopericardium with cardiac tamponade or hemothorax [1]. Ultrasonography is most helpful when positive findings reduce the time to definitive treatment. (See "Emergency ultrasound in adults with abdominal and thoracic trauma", section on 'Pericardial and limited cardiac examination'.)
An extended ultrasonographic evaluation (E-FAST) is typically performed in patients with chest trauma to look for pneumothorax [1]. Tension pneumothorax can cause hemodynamic instability due to shift of the mediastinum or compression of the superior or inferior vena cava with a profound decrease in cardiac output. Respiratory distress, unilateral breath sounds, neck vein distention, and cyanosis may also be present. Once suspected, a tension pneumothorax should be immediately treated rather than obtaining a chest radiograph (CXR) for confirmation. (See 'Pneumothorax' below and "Emergency ultrasound in adults with abdominal and thoracic trauma", section on 'Focused Assessment with Sonography for Trauma'.)
A transesophageal echocardiography (TEE) examination can also rapidly detect life-threatening conditions, such as traumatic aortic rupture, aortic dissection, pericardial fluid, left pleural effusion, severe hypovolemia, or severe right ventricular dysfunction due to myocardial contusion [2-5]. TEE is superior to transthoracic echocardiography in this setting, particularly for diagnosis of aortic rupture or dissection [2,3]. (See "Intraoperative rescue transesophageal echocardiography (TEE)".)
Use of FAST or TEE may obviate the need for CXR, computed tomography (CT), or magnetic resonance imaging (MRI) studies, thus reducing time to emergency treatment in a hemodynamically unstable patient with clinical or echocardiographic evidence of pneumothorax, severe cardiac injury, cardiac tamponade, or injuries to the major thoracic vessels.
Need for immediate lung isolation — In patients with massive hemoptysis, immediate lung isolation is necessary to prevent continued soiling of the healthy lung with blood from the injured lung (see "Evaluation and management of life-threatening hemoptysis"). Either a single-lumen endotracheal tube (ETT) with endobronchial placement to achieve lung isolation, a bronchial blocker, or a double-lumen tube may be most appropriate depending on the specific clinical situation and management plan. These management strategies are discussed separately. (See "Lung isolation techniques", section on 'Need for unilateral lung protection'.)
Stable patients — In patients who are hemodynamically stable without life-threatening airway, cardiac, pulmonary, or other vital organ injuries, diagnostic testing, typically CT, is performed before transfer of the patient to the operating room (OR) for any necessary surgical procedures. Indications for specific imaging studies depend on the mechanism of injury and clinical suspicion, as discussed in separate topics. (See "Initial evaluation and management of blunt thoracic trauma in adults", section on 'Initial evaluation and management' and "Initial evaluation and management of penetrating thoracic trauma in adults", section on 'Diagnostic testing in Stable/Stabilized Patient'.)
THORACIC TRAUMATIC INJURIES
Blunt cardiac injury — Blunt cardiac injury (also termed "cardiac contusion") is a common injury occurring in motor vehicle collisions. The right ventricle is typically involved because of its vulnerable position closest to the anterior chest wall. The spectrum of pathology ranges from transient minor arrhythmias to severe ventricular injury. Cardiac tamponade may occur after blunt trauma, although it is most often caused by a penetrating injury (see 'Cardiac tamponade' below). While blunt cardiac trauma often causes some degree of cardiac dysfunction, it rarely results in cardiogenic shock [6,7]. (See "Initial evaluation and management of blunt cardiac injury".)
After blunt cardiac injury, the electrocardiogram may show repolarization abnormalities such as ST-depression, ST-elevation, or T-wave inversion [8]. Arrhythmias such as sinus tachycardia, ventricular extrasystoles, right bundle branch block, and atrioventricular block may be present, but life-threatening arrhythmias, such as ventricular tachycardia, ventricular fibrillation, or commotio cordis (in which low-impact chest trauma causes sudden cardiac arrest) are rare [7,9]. (See "Initial evaluation and management of blunt cardiac injury", section on 'Electrocardiogram' and "Commotio cordis".)
Cardiac tamponade — Penetrating wounds of the heart often result in hemorrhagic shock or cause cardiac tamponade, depending upon whether blood can escape the pericardial space. The right ventricle is the most commonly injured chamber due to its anterior position within the chest cavity. The next most commonly injured chamber is the left ventricle. Atrial injuries are less common and typically less severe. As noted above, cardiac tamponade may also occur after blunt trauma. (See "Initial evaluation and management of penetrating thoracic trauma in adults", section on 'Cardiac injury'.)
Due to the poor compliance of the pericardium, the acute accumulation of as little as 50 mL of blood can cause tamponade physiology, a diagnosis suggested by ongoing hypotension without obvious blood loss. The faster the accumulation of blood, the more severe the hemodynamic compromise. Severe hypotension becomes evident once the volume of blood trapped in the pericardial sac increases enough to compress the heart and compromise cardiac output [10]. However, if the rate of bleeding is slow or the pericardium periodically decompresses by emptying blood into the pleural space, a patient may initially appear stable. A narrowed pulse pressure and the presence of pulsus paradoxus are important diagnostic signs of cardiac tamponade [11]. Focused assessment with sonography for trauma (FAST) can provide an accurate (ie, sensitive and specific) diagnosis of cardiac injury in patients with a penetrating chest wound [12]. (See "Cardiac tamponade" and "Emergency ultrasound in adults with abdominal and thoracic trauma", section on 'Pericardial and limited cardiac examination'.)
Severe cardiac tamponade requires urgent treatment, with either surgical drainage (eg, subxiphoid pericardial window or median sternotomy and pericardiotomy) or catheter drainage. Relatively stable patients are evaluated with FAST or transesophageal echocardiography (TEE), either in the operating room (OR) or the emergency department (ED). For hemodynamically unstable patients, emergency pericardiocentesis and placement of a catheter may be necessary to provide temporary relief, and is a reasonable option when surgical treatment is not immediately available. However, this procedure may be technically challenging because of the need to locate a potentially small amount of fluid causing tamponade physiology, and because clotted blood can be difficult to aspirate through a thin catheter. Further details regarding treatment options in specific situations are discussed in other topics:
●(See "Pericardial effusion: Approach to management".)
●(See "Emergency pericardiocentesis".)
●(See "Management of cardiac injury in severely injured patients".)
Myocardial or vascular injury with hemorrhagic shock — Any patient with a penetrating wound to the chest, back, neck, or abdomen can have a myocardial or vascular injury and may develop hemorrhagic shock. Also, patients involved in high-energy blunt trauma (eg, rapid deceleration) are at significant risk for aortic injury or disruption with consequent hemorrhage. Drainage of large amounts of blood upon placement of a chest tube suggests a major myocardial or vascular injury with hemorrhage that is unlikely to stop without surgical intervention.
In selected patients, emergency thoracotomy may be performed in the ED if expertise is available. A left anterolateral thoracotomy enables several potentially life-saving maneuvers, including temporary repair of penetrating myocardial wounds, pericardiotomy to decompress cardiac tamponade, cross-clamping of the descending thoracic aorta (thereby preventing exsanguinating hemorrhage in the abdomen and increasing perfusion of the brain and heart), or open cardiac massage during transport to the OR for emergency surgery. Discussions regarding decision-making and techniques for emergency thoracotomy are available in other topics. (See "Resuscitative thoracotomy: Technique" and "Initial evaluation and management of penetrating thoracic trauma in adults", section on 'Role of emergency department thoracotomy'.)
Anesthetic management of cardiac or vascular injuries in the OR may involve cardiopulmonary bypass, as discussed below (see 'Repair of cardiac or thoracic vascular injuries' below). Other aspects of initial evaluation and surgical management of blunt and penetrating injuries to the myocardium and thoracic blood vessels are discussed in separate topics:
●(See "Initial evaluation and management of blunt thoracic trauma in adults".)
●(See "Initial evaluation and management of penetrating thoracic trauma in adults".)
●(See "Overview of blunt and penetrating thoracic vascular injury in adults".)
Tracheobronchial injury — Tracheobronchial injuries are highly lethal at the scene of the traumatic event as well as during subsequent treatment, in part due to difficulties in establishing a definitive airway and problems with oxygenation and ventilation [13-16]. Most injuries occur within 2 cm of the carina, owing to the rapid deceleration of the relatively mobile lungs against a fixed carina. This tracheobronchial tearing usually occurs near the bifurcation of the carina [14,15], more often on the right side due to a shorter right mainstem bronchus and a heavier/larger right lung. (See "Identification and management of tracheobronchial injuries due to blunt or penetrating trauma".)
Signs of a likely tracheobronchial injury include difficulty breathing or dyspnea, subcutaneous or mediastinal emphysema, cough, hemoptysis, stridor, pneumothorax (especially with a large air leak or with a failure to expand the lung after tube thoracostomy), tension pneumothorax, or air bubbling from a penetrating wound. However, the diagnosis may not be made prior to the need for tracheal intubation. (See "Initial evaluation and management of blunt thoracic trauma in adults", section on 'Tracheobronchial injury' and "Initial evaluation and management of penetrating thoracic trauma in adults", section on 'Tracheobronchial injury'.)
Definitive diagnosis of tracheobronchial injuries is made with the aid of bronchoscopy or during surgical exploration. However, the anesthesiologist may be called to the ED to assist with securing the airway before transport to the OR. Airway management can be challenging, particularly if tracheal injury is within 2 cm of the carina. The American Society of Anesthesiologists Committee on Trauma and Emergency Preparedness has developed guidance for these situations (algorithm 2 and table 1 and table 2) [17]. Further information is available in the following topics:
●(See "Anesthesia for adult trauma patients", section on 'Airway management'.)
●(See "Airway management in the adult with direct airway trauma for emergency medicine and critical care".)
●(See "Management of the difficult airway for general anesthesia in adults".)
●(See "Anesthesia for patients with acute traumatic brain injury", section on 'Airway management'.)
●(See "Overview of advanced airway management in adults for emergency medicine and critical care".)
Subsequent surgical repair is typically necessary in patients with ongoing risk for airway obstruction, massive air leak, or mediastinitis [18] (see 'Repair of tracheobronchial injury' below). Coexisting injuries are common, including pulmonary contusions, chest wall injuries, and fractures of the first rib, clavicle, and sternum. (See 'Pulmonary contusion' below and 'Chest wall injury' below.)
Pulmonary contusion — Pulmonary contusion complicates approximately 65 percent of blunt chest trauma cases presenting for emergency surgery [19]. It is likely in patients who have tachypnea, hypoxia, hypercarbia, wheezing, or hemoptysis. However, chest radiograph (CXR) and computed tomography (CT) findings may not appear until hours after clinical signs. An extended ultrasonographic evaluation (E-FAST) may provide more rapid evaluation and diagnosis compared with these other imaging modalities [20,21]. (See "Pulmonary contusion in adults".)
After pulmonary contusion, loss of vessel integrity at the alveolar capillary membrane leads to intraparenchymal and alveolar hemorrhage and edema, with decreased surfactant production and development of pulmonary shunting. The lung becomes functionally smaller as alveoli fill with blood and edema. In the postoperative period, splinting due to pain leads to progressive atelectasis and inflammatory responses to the local lung injury often result in acute respiratory distress syndrome. Supportive care includes optimal pain management (with epidural or paravertebral block placement when possible) [22], as well as lung protective ventilation. (See 'Postoperative management' below.)
Rarely, venovenous extracorporeal membrane oxygenation (ECMO) may be necessary. (See "Extracorporeal life support in adults in the intensive care unit: Overview".)
Pleural abnormalities — The pleural space is normally a potential space filled with a thin film of serous fluid that separates the visceral pleura that covers each lung and the parietal pleura that covers the inner chest wall.
Pneumothorax — Air can enter the pleural space after trauma (ie, open pneumothorax) or, more commonly, from a disruption in the visceral pleura that causes air to escape from the lung or the tracheobronchial tree into the pleural space. The potential for a pneumothorax exists in patients with injury to the lung parenchyma, trachea, bronchi, or chest wall itself. Air in the pleural space that is not under pressure has a variable clinical presentation ranging from absence of symptoms to severe pleuritic chest pain, dyspnea, and tachypnea. The diagnosis is typically made by CXR. (See "Initial evaluation and management of blunt thoracic trauma in adults", section on 'Pneumothorax' and "Initial evaluation and management of penetrating thoracic trauma in adults", section on 'Pneumothorax'.)
A small pneumothorax may become a tension pneumothorax, particularly if positive pressure ventilation is applied (eg, after endotracheal intubation). Positive pressure building in the pleural space leads to lung collapse and mediastinal shift, which can compromise caval connections to the right atrium and result in severely decreased cardiac output. Signs of tension pneumothorax include tracheal deviation, jugular venous distention, unilateral breath sounds, hypotension, and cyanosis (a late finding).
If a tension pneumothorax is suspected, immediate treatment in the ED is necessary, rather than obtaining a CXR for confirmation. The goal is immediate relief of pressure in the pleural space and restoration of venous return to the heart. A standard thoracostomy tube (24 or 28 Fr in adults) is placed if equipment and personnel are immediately available; otherwise, needle thoracostomy should be performed as a life-saving measure to reduce intrapleural pressure. Once the patient is out of immediate danger, a standard chest tube is placed. (See 'Tube thoracostomy' below.)
These procedures are described in other topics:
●(See "Thoracostomy tubes and catheters: Placement techniques and complications", section on 'Techniques'.)
Since a conservatively treated or previously undiagnosed pneumothorax may become a tension pneumothorax when positive pressure ventilation is applied, clear communication to the anesthesia team regarding possible presence of a pneumothorax should occur before the patient is transported to the OR [23,24].
Hemothorax — Blood can enter the pleural space after traumatic thoracic injury. Clinically significant hemothorax (>1500 cc total or >200 cc/hour for four hours) should be suspected in any trauma patient with shock or absent or distant breath sounds on one side [25]. Injuries leading to this grave situation are usually large lacerations to the pulmonary parenchyma or injury to an intercostal artery, internal thoracic (mammary) artery, great vessel, or cardiac chamber. Hemodynamically unstable patients are taken to the OR for emergency exploration to repair both intrathoracic and/or intraabdominal sources of bleeding. As noted above, in selected patients emergency thoracotomy may be performed in the ED. (See 'Myocardial or vascular injury with hemorrhagic shock' above and "Resuscitative thoracotomy: Technique".)
Small hemothoraces are more common with variable clinical presentations. Similar to a pneumothorax, symptoms may be absent or the patient may have severe pleuritic chest pain and dyspnea with decreased breath sounds and dullness to percussion. Imaging modalities include E-FAST, CXR, and CT imaging. (See "Initial evaluation and management of blunt thoracic trauma in adults", section on 'Hemothorax' and "Initial evaluation and management of penetrating thoracic trauma in adults", section on 'Hemothorax and vascular injury'.)
Typically, tube thoracostomy is selected to treat a hemothorax (see 'Tube thoracostomy' below), although some small asymptomatic collections of blood may be managed by observation only [25].
Esophageal injury — Emergency surgery is necessary for patients with esophageal injury; anesthetic management is discussed separately. (See "Overview of esophageal injury due to blunt or penetrating trauma in adults" and "Anesthesia for esophagectomy and other esophageal surgery", section on 'Repair of esophageal perforation or rupture'.)
Diaphragmatic injury — Traumatic injuries to the diaphragm are very often associated with other injuries including injury to visceral solid organs, such as liver and spleen, as well as hollow viscous injury. Injuries to the thorax including to the aorta, lung, and chest wall are also possible. As such, the anesthesiologist should be prepared to address both significant hemorrhage and airway control with possible lung isolation. (See "Recognition and management of diaphragmatic injury in adults".)
Chest wall injury — Management of chest wall injuries due to blunt thoracic trauma includes adequate pain control to prevent pain-associated splinting that leads to inadequate ventilation, weak cough, atelectasis, pneumonia, and possibly prolonged mechanical ventilation and intensive care unit (ICU) stays [26]. (See "Initial evaluation and management of chest wall trauma in adults".)
Rib fractures — Rib fractures are present in approximately 10 percent of all trauma patients [27]. They are a marker for more severe injuries, and are associated with significant morbidity and mortality, particularly in older patients [28].
Multimodal pain therapy is the primary treatment for most patients who have rib fractures without a flail chest [29]. Although choices include multiple regional analgesic techniques (thoracic epidural analgesia, thoracic paravertebral block, erector spinae plane block, intercostal nerve blocks, serratus anterior plane block for anterolateral rib fractures), as well as systemic opioid administration, data suggesting superiority of any one technique are scant (figure 1) [29,30]. Furthermore, some regional techniques are not efficacious in patients with bilateral rib fractures, or have limited use due to lack of clinician familiarity with the block or inability to place a catheter for continuous infusion of local anesthetic. (See 'Pain management' below and "Inpatient management of traumatic rib fractures and flail chest in adults", section on 'Pain control'.)
Selected patients may benefit from surgical rib fracture fixation. Fixation is typically performed after initial management of thoracic injuries in patients with severe rib fractures who are refractory to pain management strategies and have impending or actual respiratory failure. (See "Surgical management of severe rib fractures".)
Flail chest — Flail chest occurs when three or more adjacent ribs are each fractured in two places, creating a floating segment and unstable chest wall (figure 2) [31]. This loss of continuity with the remainder of the rib cage causes the flail segment to move paradoxically. Pressure within the chest is negative during inspiration, causing the flail segment to retract. With expiration, intrathoracic pressure becomes positive and the flail segment bulges. Adverse physiologic effects may include inefficient ventilation, hypoventilation, atelectasis, pulmonary shunt, ventilation-perfusion mismatch, and hypoxemia. (See "Initial evaluation and management of chest wall trauma in adults", section on 'Flail chest' and "Initial evaluation and management of blunt thoracic trauma in adults", section on 'Chest wall injury'.)
Flail chest injuries are often associated with coexisting pulmonary contusion, lung lacerations that may lead to pneumothorax or hemothorax, or injuries to other thoracic and extrathoracic structures. Initial treatment may be dictated by other underlying injuries [31]. If endotracheal intubation with positive pressure ventilation is necessary, the mechanically discordant movement of the chest wall caused by the flail segment itself is eliminated. Noninvasive ventilation has also been employed in selected patients to minimize the sequelae of paradoxical movements [32]. (See "Initial evaluation and management of chest wall trauma in adults", section on 'Flail chest' and "Initial evaluation and management of blunt thoracic trauma in adults", section on 'Chest wall injury'.)
ANESTHETIC MANAGEMENT: GENERAL CONSIDERATIONS — Checklists are often used as a cognitive aid to guide the anesthesiology team during emergency preparations for intraoperative resuscitative care of any trauma patient (table 3) [33,34]. (See "Anesthesia for adult trauma patients".)
General anesthesia
●Induction – Urgent airway management in trauma patients may be challenging due to the presence of a cervical collar or other injuries, as discussed separately (algorithm 2). (See "Anesthesia for adult trauma patients", section on 'Airway management'.)
Patients who arrive in the operating room (OR) already intubated and sedated may not need an intravenous (IV) induction agent, although low doses of narcotics, sedatives, or a volatile anesthetic agent will be needed for maintenance of anesthesia during the surgical procedure.
In stable patients who require anesthetic induction, use of a short-acting sedative-hypnotic agent (eg, ketamine 1 to 2.5 mg/kg, etomidate 0.3 mg/kg, or a reduced dose of propofol eg, 0.5 mg/kg), a moderate dose of narcotic (eg, fentanyl [1 mcg/kg]), and a neuromuscular blocking agent (NMBA) with rapid onset (typically succinylcholine) is a reasonable approach. In hemodynamically unstable patients, adjunct anesthetic agents (eg, opioids, lidocaine, midazolam) are avoided (table 4). In extreme situations, any induction agent is administered in a low dose or avoided altogether. (See "Anesthesia for adult trauma patients", section on 'Induction'.)
If a patient suffers significant hypotension and or bradycardia shortly after endotracheal intubation and initiation of positive pressure ventilation, a diagnosis of tension pneumothorax should be suspected, with a low threshold for presumptive treatment. (See 'Pneumothorax' above.)
●Maintenance – Anesthesia is maintained with low-to-normal concentrations of a potent volatile anesthetic agent as needed, supplemented with opioids and other IV agents as tolerated, and with a NMBA if indicated to prevent movement.
●Emergence – The decision to extubate the patient at the end of the procedure depends on cardiopulmonary stability, the extent of the traumatic injuries sustained, the surgical procedure(s) performed, and the likelihood that additional surgical procedures will soon be necessary.
Hemodynamic management
●Monitoring – Any surgical intervention for major traumatic cardiopulmonary injury warrants placement of an intra-arterial catheter as soon as possible, ideally prior to induction. In patients with suspected aortic injuries, a single arterial catheter is best placed in the right radial artery, and in instances where transection is suspected, the surgical team may request a placement of a left radial arterial catheter as well.
Two large-bore peripheral IV catheters (eg, 16 G or larger) are typically inserted instead of or in addition to a central venous catheter for initial administration of fluid, blood transfusions, and IV vasoactive and anesthetic agents. In patients who have significant laterality to their injuries (eg, a gunshot wound to their left shoulder), IV access and arterial pressure monitoring should be performed on the contralateral side. (See "Anesthesia for adult trauma patients", section on 'Intravascular access and monitoring'.)
If acute, persistent, or life-threatening circulatory instability is present, intraoperative use of transesophageal echocardiography (TEE) should be considered to diagnose the cause ("rescue echo") and to direct specific treatment. (See "Intraoperative rescue transesophageal echocardiography (TEE)".)
●Arrhythmias – Transcutaneous pacing/defibrillation pads should be placed prior to induction of anesthesia if possible, since hemodynamically unstable arrhythmias may occur following blunt cardiac injury (eg, high-grade conduction blocks, new onset atrial fibrillation, supraventricular or ventricular tachycardia). Management of specific arrhythmias is discussed separately. (See "Arrhythmias during anesthesia" and "Advanced cardiac life support (ACLS) in adults", section on 'Management of specific arrhythmias'.)
●Inotropic and vasopressor agents – Inotropic (eg, epinephrine) and/or vasopressor (eg, norepinephrine or vasopressin) support is often temporarily necessary to maintain cardiac output and blood pressure (eg, in patients with cardiac tamponade or severe myocardial contusion) (table 5). However, it is critically important to identify and treat hypovolemia when that is the cause of hemodynamic instability [7].
Fluid management — Red blood cells should be immediately available, and are administered as necessary. Further discussion is available in separate topics. (See "Intraoperative transfusion and administration of clotting factors", section on 'Red blood cells' and "Massive blood transfusion", section on 'Trauma'.)
After initial resuscitation and achievement of hemodynamic stability, administration of fluids should be judicious to minimize edema formation in injured lung. Hypotensive resuscitation is a commonly employed method to attain this goal. Dynamic assessments are typically employed to predict fluid responsiveness (improvement in cardiac output; eg, arterial waveform analysis), rather than older static measurements, such as central venous pressure. (See "Intraoperative fluid management", section on 'Monitoring intravascular volume status' and "Intraoperative fluid management", section on 'Dynamic parameters to assess volume responsiveness'.)
Ventilation management — Lung protective strategies are employed during mechanical ventilation. (See "Mechanical ventilation during anesthesia in adults", section on 'Lung protective ventilation during anesthesia'.)
In patients with right ventricular contusion, mechanical ventilation is adjusted to minimize mean airway pressure; high inspiratory pressures and high levels of positive end-expiratory pressure (PEEP) are avoided if possible [35]. (See "Anesthesia for noncardiac surgery in patients with pulmonary hypertension or right heart failure", section on 'Management of ventilation'.)
Selected patients require lung isolation for completion of the planned thoracic surgical procedure. Techniques to accomplish lung isolation and principles of one lung ventilation are discussed separately. (See "Lung isolation techniques" and "One lung ventilation: General principles".)
ANESTHETIC CONSIDERATIONS FOR SPECIFIC PROCEDURES — Surgical and anesthetic goals vary for specific traumatic thoracic injuries.
Tube thoracostomy — Although a tube thoracostomy to treat pneumothorax or hemothorax is generally a straightforward procedure, a variety of complications can occur, including cardiac injury, intercostal arterial injury, lung parenchymal injury, accidental extrapleural tube placement, or subdiaphragmatic placement leading to intraabdominal injury and bleeding (spleen, liver). (See "Overview of anesthetic management for patients with pleural disease", section on 'Catheter drainage of pleural effusions'.)
Patients who have persistent chest radiograph (CXR) opacities after initial tube thoracostomy may have retained hemothorax requiring surgical removal [36]. Video-assisted thoracoscopic surgery (VATS) is typically employed within the first three to seven days of traumatic injury to reduce the risk of development of empyema or fibrothorax (trapped lung) [25]. Anesthetic management for thoracic VATS procedures is discussed separately. (See "Anesthesia for video-assisted thoracoscopic surgery (VATS) for pulmonary resection".)
Surgical drainage of cardiac tamponade — Anesthetic management of patients with pericardial tamponade is discussed in a separate topic. (See "Anesthesia for patients with pericardial disease and/or cardiac tamponade", section on 'Treatment of pericardial effusion and/or tamponade'.)
Repair of cardiac or thoracic vascular injuries — As noted above, blood and vasoactive agents should be immediately available (table 3 and table 5). (See "Anesthesia for adult trauma patients", section on 'Intraoperative management of hemorrhagic shock'.)
Anesthetic management of myocardial injuries typically involves cardiopulmonary bypass (CPB); details are discussed separately. (See "Initiation of cardiopulmonary bypass" and "Management of cardiopulmonary bypass".)
For some penetrating cardiac injuries, repair without the use of CPB may be possible, thereby avoiding systemic anticoagulation in a patient who may have several major traumatic injuries [37]. Adenosine may provide the surgeon with 15 or 20 seconds of asystole to facilitate the cardiac repair [38].
Details regarding anesthetic management for severe vascular injuries are discussed in separate topics:
●(See "Anesthesia for endovascular aortic repair".)
●(See "Anesthesia for open descending thoracic aortic surgery".)
●(See "Anesthesia for aortic surgery with hypothermia and elective circulatory arrest in adult patients".)
Repair of tracheobronchial injury — In patients with tracheobronchial injury, spontaneous ventilation is maintained if possible (algorithm 2) [17].
Fiberoptic bronchoscopy (FOB) is a critical tool for both assessing the injury and securing the airway [14]. Knowledge of the location of injury is critical, and attempts at blind instrumentation can be disastrous [39]. In most cases, the goal is to place the cuff of the endotracheal tube (ETT) beyond the site of injury to protect the site from exposure to positive pressure ventilation.
A side-specific double-lumen endotracheal tube is typically appropriate, although caution must be exercised in pushing a bulky rigid tube past an already injured airway. Passing the cuff of a single-lumen ETT beyond the injury and then using a bronchial blocker for lung isolation may be more prudent for more proximal injuries, and has the added advantage of avoiding a need to change the ETT at the end of the procedure if the patient must remain intubated. (See "Lung isolation techniques", section on 'Abnormal tracheobronchial anatomy' and "Lung isolation techniques", section on 'Need for postoperative ventilation'.)
Most patients undergo endobronchial stenting, primary repair, or possible lung resection, although use of nonoperative management has been reported in selected patients [15,16,40-42]. (See "Identification and management of tracheobronchial injuries due to blunt or penetrating trauma".)
In one series, maneuvers necessary to secure the airway included FOB, creation of a surgical airway, or creation of a temporary airway through the wound [13]. In rare cases, heroic measures have been used, including extracorporeal membrane oxygenation, thoracotomy, jet ventilation via intrabronchial catheters, and cross field ventilation (with direct intubation of the main conducting airway distal to the injured tracheal area) [43-45].
Repair of esophageal injury — Anesthetic management for emergency repair of esophageal injury is discussed separately. (See "Anesthesia for esophagectomy and other esophageal surgery", section on 'Repair of esophageal perforation or rupture'.)
Rib fracture fixation — In selected patients, particularly those with flail chest, surgical rib fracture fixation is employed, typically using rib plating techniques [46]. Usually, there is no need for intraoperative lung isolation. (See "Surgical management of severe rib fractures", section on 'Rib fracture stabilization'.)
POSTOPERATIVE MANAGEMENT
General considerations — Most patients with blunt or penetrating cardiac injury require 24 to 48 hours of monitoring in an intensive care unit (ICU) due to the ongoing possibility of arrhythmias and myocardial dysfunction, even if there were no other major traumatic injuries.
A standard approach for patients with thoracic trauma at the author's institution includes criteria for ICU admission (eg, all patients >45 years old with four or more rib fractures and those >65 years old with two or more rib fractures) and emphasis on pain control and optimal pulmonary toilet. The anesthesia service is consulted for placement of an epidural catheter if patient-controlled analgesia (PCA) with an intravenous (IV) opioid supplemented with IV ketorolac does not provide adequate analgesia, particularly if the patient has poor cough or incentive spirometry performance. Lung protective ventilation strategies are employed for patients who remain intubated with controlled mechanical ventilation. (See "Acute respiratory distress syndrome: Ventilator management strategies for adults".)
Pain management — Providing optimal analgesia for patients with painful traumatic thoracic injuries may improve outcomes. A multimodal approach is typically employed (ie, a combination of analgesics and techniques, each with a different mechanism of action within the central or peripheral nervous system) [47-49]. This approach may include IV opioid analgesics, regional analgesic techniques, and nonopioid IV agents. Potential advantages of a multimodal approach include improved analgesia, reduced opioid dosing to achieve effective analgesia, and decreased risk of opioid-related side effects. (See "Pain control in the critically ill adult patient", section on 'Multimodal analgesia'.)
Intravenous opioid and nonopioid agents
●Opioid analgesics – IV opioids are administered via PCA when possible, and remain a first-line treatment for pain management in patients with chest trauma, particularly those requiring endotracheal intubation and mechanical ventilation. Advantages of opioids include their efficacy, rapid onset, and ease of titration. However, in nonintubated patients, adverse effects including respiratory depression, cough suppression, and sedation lead to atelectasis, sputum retention, decreased functional residual capacity (FRC), and worsening hypoxia due to ventilation-perfusion mismatch. These effects increase risk for needing to institute mechanical ventilation, particularly in older patients and those with rib fractures [27,28,50,51]. Further details regarding the benefits and adverse effects of IV opioids are available in a separate topic. (See "Pain control in the critically ill adult patient", section on 'Opioid analgesics'.)
●Nonopioid analgesics – Nonopioid analgesic agents may be employed as adjuncts to supplement pain control. These include ketorolac, other nonsteroidal antiinflammatory drugs, and acetaminophen. No data are available for patients with traumatic thoracic injury, but these adjuncts are often used for outpatient management of fractured ribs and as a component of multimodality therapy after thoracic video-assisted surgery (VATS). (See "Anesthesia for video-assisted thoracoscopic surgery (VATS) for pulmonary resection", section on 'Management of VATS pain' and "Nonopioid pharmacotherapy for acute pain in adults".)
Regional analgesic techniques — We typically select thoracic epidural analgesia (TEA) or paravertebral block (PVB) as the first-line regional analgesic modality for pain control after thoracic trauma, although various options are available [29,30,49,52]. Regional analgesia with either of these techniques has been associated with a 35 percent reduction in delirium in older adults [53]. (See "Anesthesia for open pulmonary resection", section on 'Choice of technique'.)
●Paravertebral blocks – The PVB technique is a common first-line regional analgesic technique in the setting of thoracotomy or blunt thoracic trauma [54,55]. PVB involves blockade of the intercostal nerve and its dorsal ramus as well as the sympathetic chain, producing a dense sensory and sympathetic block [54]. (See "Thoracic paravertebral block procedure guide".)
Compared with TEA, catheter-based PVB with continuous infusion of a local anesthetic agent provides comparable analgesia and may be associated with fewer adverse side effects (eg, hypotension, respiratory depression, nausea, vomiting, urinary retention) after elective thoracotomy or blunt thoracic trauma [55-62]. The lower risk of adverse effects may be due to the unilateral placement of a PVB (resulting in less risk of hypotension), and the use of local anesthetic agents without opioids (resulting in a lower risk of respiratory depression, nausea, vomiting and urinary retention) (see "Anesthesia for open pulmonary resection", section on 'Paravertebral block'). Also, PVB catheter placement may be safer than epidural catheter placement in patients who are sedated or for those who require mechanical ventilation [26,63].
For these reasons, use of the PVB technique has increased in thoracic trauma patients (either continuous infusion of local anesthetic or a single shot) [54,55]. Small studies in patients with multiple fractured ribs have noted benefits after placement of a PVB (eg, improved pain scores, bedside spirometry measurements, and arterial blood gases, as well as reduced analgesic requirements [64,65]. In an observational study using the National Trauma Database, 1073 patients who received TEA for rib fractures were compared with 1110 propensity-matched patients who received analgesia via PVB, with no differences noted for outcomes including mortality, duration of mechanical ventilation, development of pneumonia, and hospital length of stay [52]. Another observational study in 290 consecutive patients with rib fractures noted that PVB placed with ultrasound guidance resulted in similar safety and efficacy compared with use of systemic analgesia, with a nonsignificant trend toward lower mortality [66]. However, there are no randomized trials directly comparing TEA versus PVB techniques in such patients.
The technique for placement of a thoracic PVB block is described separately. Placement of a PVB catheter is relatively easy for experienced clinicians, although difficulty with threading the catheter into the paravertebral space occasionally occurs [64,67]. Ultrasound-guided techniques may be used to improve ease and safety of PVB placement (picture 1 and picture 2). (See "Thoracic paravertebral block procedure guide".)
Challenges for PVB use in the setting of thoracic trauma include lack of familiarity with the technique among anesthesiologists. Also, nerve blockade with PVB is typically unilateral, which may be a disadvantage after some traumatic thoracic injuries. If bilateral catheter placement is considered for a patient with bilateral rib fractures, then strict attention to total local anesthetic dose is particularly critical. Finally, although safety of PVB catheter placement is generally considered to be comparable or superior to TEA catheter placement, complications can occur. For example, in two small series of patients with multiple rib fractures, accidental placement of the catheter in the epidural space with resultant hypotension was reported in one patient [64], and seizure activity due to local anesthetic toxicity occurred in one patient [55]. In other settings, pneumothorax, accidental vascular or dural puncture, and accidental placement of the catheter in the pleural space have been reported [64,68-70].
●Thoracic epidural analgesia – Continuous TEA remains a common first-line regional analgesic technique in the setting of thoracotomy or blunt thoracic trauma, although there is limited evidence for benefit or harm of TEA for traumatic rib fractures compared with other analgesic techniques in terms of mortality, duration of mechanical ventilation, or pneumonia [26,71]. (See "Anesthesia for open pulmonary resection", section on 'Thoracic epidural analgesia'.)
TEA with a combination of local anesthetic and opioids is more effective than either alone, providing nearly immediate bilateral thoracic pain relief [56]. Compared with systemic analgesics, use of TEA results in less sedation; thus, patients can participate in pulmonary toilet [72]. Use of TEA increases FRC, vital capacity, tidal volume, and lung compliance, decreases the movement of flail segments, and increases PaO2 [63,73,74]. In a systematic review, epidural analgesia improved outcomes including pain relief and pulmonary function in chest trauma patients with three or more rib fractures compared with systemic opioid administration [75]. Small randomized trials comparing TEA with systemic opioids for management of patients with multiple rib fractures have noted a decrease in incidence of nosocomial pneumonia and duration of mechanical ventilation [76], larger tidal volume, fewer days on mechanical ventilation, fewer tracheostomies, and shorter ICU and hospitalization stays when TEA was used [73]. These studies did not employ patient-controlled epidural analgesia or programmed intermittent epidural bolus, which may have further improved pain control. Continuous TEA after thoracic trauma may also decrease serum levels of IL-8, a proinflammatory chemoattractant that has been implicated in acute lung injury [77]. (See "Anesthesia for open pulmonary resection", section on 'Thoracic epidural analgesia' and "Continuous epidural analgesia for postoperative pain: Technique and management".)
Placement of an epidural catheter may be challenging in an awake trauma patient with acute pain. Epidural catheters and/or use of epidural analgesia are avoided in patients with hemodynamic instability, coagulopathy, spinal trauma, traumatic brain injury, or other causes of altered mental status. (See "Overview of neuraxial anesthesia", section on 'Preoperative evaluation' and "Epidural and combined spinal-epidural anesthesia: Techniques", section on 'Epidural anesthesia technique'.)
Adverse effects and complications of TEA include hypotension, especially in the hypovolemic patient or after large-volume boluses with local anesthetic. Less serious adverse effects include pruritus, nausea, and urinary retention, and are more common when the epidural solution contains opioids. Epidural infection is a rare complication in chest trauma patients [72]. (See "Overview of neuraxial anesthesia", section on 'Adverse effects and complications'.)
●Erector spinae plane block – The erector spinae plane block is another newer myofascial plane block that is particularly useful for management of pain after extensive thoracic surgery or trauma because it provides analgesia to both the anterior and posterior hemithorax, in contrast with the serratus anterior plane block [30]. In one retrospective study in 79 patients with rib fractures, use of erector spinae plane blocks improved short-term inspiratory capacity and pain scores without evidence of hemodynamic instability [78]. Use of this block is increasing for thoracic trauma patients and in other settings, although data regarding efficacy are scant [30,79]. Still, it may be an attractive alternative to epidural or paravertebral blocks in patients with bony injury to the thoracic spine, typically a contraindication for neuraxial techniques [80]. Since it is a plane block, catheters may be left in place; however, periodic large volume boluses may be necessary to achieve adequate analgesia. Risk for pneumothorax or neurovascular injury is low compared with epidural or PVB. The erector spinae plane block is typically performed in the sitting position using ultrasound guidance [29]. (See "Erector spinae plane block procedure guide".)
●Serratus anterior plane block – Serratus anterior plane block is another newer technique for treatment of pain after thoracotomy or blunt thoracic injury [29,30,81-83]. The technique offers a less invasive approach in patients with rib fractures who have contraindications to more invasive techniques [84,85]. The serratus anterior plane block is typically performed in the supine position using ultrasound guidance, thus sparing the patient the discomfort of being placed in the lateral or sitting position for other plane and neuraxial blocks (image 1) [29]. (See "Thoracic nerve block techniques", section on 'Serratus plane block'.)
●Intercostal nerve blocks – Intercostal nerve blocks have been used in patients with blunt chest trauma and multiple rib fractures [29,63], as well as after thoracotomy procedures (figure 3 and figure 4 and image 2) [86,87]. Injections of the intercostal nerve are performed proximal to the point of injury in interspaces both above and below the injured ribs. While some clinicians advocate blocking intercostal nerves proximal to the midaxillary line (to ensure blockade of the lateral and anterior cutaneous branches of the intercostal nerve), this should only be necessary when analgesia of the skin is required [63]. (See "Thoracic nerve block techniques", section on 'Intercostal nerve block'.)
Advantages of intercostal nerve blocks include improvement in peak expiratory flow rate as well as arterial oxygen and carbon dioxide tensions [88-90]. Also, intercostal blocks do not produce sedation, respiratory depression, or other side effects associated with systemic or regional opioid administration, and unilateral placement results in minimal hemodynamic effects. Thus, these blocks have been a viable alternative for patients who have contraindications to or unsuccessful attempts for placement of an epidural catheter or PVB.
However, limitations of intercostal nerve block placement include the need to palpate fractured ribs, which can be painful. Also, the analgesic effect of the block lasts only a few hours. Furthermore, placement and maintenance of an intercostal catheter in a precise location to facilitate repeated injections is challenging [26,91,92]. In addition, multiple injections increase risk for causing a pneumothorax (a risk is estimated to be >1 percent for each individual intercostal nerve that is blocked or up to 9 percent in patients requiring multiple intercostal nerve blocks [93]) or for inducing local anesthetic toxicity. However, many trauma patients need only one or two injections, and the risk of pneumothorax is obviated in patients with a tube thoracostomy in place [93].
●Intrapleural analgesia – A less effective approach to analgesia involves infusion of local anesthetics directly into the pleural space, either via an indwelling thoracostomy tube or with placement of a dedicated intrapleural catheter [90,94]. This technique is rarely used now due to development of newer alternatives to epidural anesthesia (eg, serratus anterior or erector spinae blocks) that also have little hemodynamic sequelae [30]. (See "Inpatient management of traumatic rib fractures and flail chest in adults".)
CONSIDERATIONS DURING THE COVID-19 PANDEMIC — During the COVID-19 pandemic, urgent thoracic surgery may be necessary for patients with thoracic trauma [95]. Key principles for infection control and airway management in such patients are discussed separately. (See "One lung ventilation: General principles", section on 'One lung ventilation in covid-19 patients' and "Overview of infection control during anesthetic care", section on 'Infectious agents transmitted by aerosol (eg, COVID-19)'.)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Thoracic trauma".)
SUMMARY AND RECOMMENDATIONS
●Initial resuscitation and management strategies for thoracic trauma patients are based on Advanced Trauma Life Support (ATLS) protocols that emphasize assessing and stabilizing the patient's airway, breathing, and circulation (ie, ABCs) (algorithm 1). In particular, life-threatening issues such as airway obstruction, tension pneumothorax, cardiac tamponade, massive hemothorax, and flail chest require emergency interventions. (See 'General considerations' above.)
●In a hemodynamically unstable patient, emergency ultrasonographic evaluation is performed if feasible (Extended Focused Assessment with Sonography for Trauma [E-FAST]), including assessment for tension pneumothorax, hemopericardium with cardiac tamponade, or hemothorax. The algorithm provides guidance for management of a difficult airway in patients with traumatic airway injury or obstruction (algorithm 2). In patients with massive hemoptysis, immediate lung isolation with either a single-lumen endotracheal tube (ETT) with endobronchial placement to achieve lung isolation or a double-lumen tube is necessary to prevent continued soiling of the healthy lung with blood from the injured lung. (See 'Hemodynamic instability' above.)
●Anesthetic implications for specific traumatic thoracic injuries are described above:
•(See 'Blunt cardiac injury' above.)
•(See 'Cardiac tamponade' above.)
•(See 'Myocardial or vascular injury with hemorrhagic shock' above.)
•(See 'Tracheobronchial injury' above.)
•(See 'Pulmonary contusion' above.)
•(See 'Pleural abnormalities' above.)
-(See 'Pneumothorax' above.)
-(See 'Hemothorax' above.)
•(See 'Esophageal injury' above.)
•(See 'Diaphragmatic injury' above.)
•(See 'Chest wall injury' above.)
●A checklist is useful during emergency preparations for intraoperative resuscitative care of any trauma patient (table 3). Surgical intervention for major traumatic cardiopulmonary injury warrants placement of an intra-arterial catheter as soon as possible, ideally prior to induction of general anesthesia. Inotropic (eg, epinephrine) and/or vasopressor (eg, norepinephrine or vasopressin) support is often temporarily necessary to maintain cardiac output and blood pressure (table 5). After initial resuscitation and achievement of hemodynamic stability, administration of fluids should be attentive to minimize edema formation in injured lung; dynamic assessments to predict fluid responsiveness are typically employed. (See 'Anesthetic management: General considerations' above.)
●Surgical and anesthetic goals vary for specific traumatic thoracic injuries:
•(See 'Tube thoracostomy' above.)
•(See 'Repair of cardiac or thoracic vascular injuries' above.)
•(See 'Repair of tracheobronchial injury' above.)
•(See 'Repair of esophageal injury' above.)
•(See 'Rib fracture fixation' above.)
●Most patients with blunt or penetrating cardiac injury require 24 to 48 hours of monitoring in an intensive care unit due to the ongoing possibility of arrhythmias and myocardial dysfunction. A multimodal approach is typically employed to provide optimal analgesia for patients with painful thoracic injuries; this may include intravenous (IV) opioid analgesics, regional analgesic techniques, and nonopioid IV agents. (See 'Postoperative management' above.)
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