Version July 2025
INTRODUCTION —
Blunt or penetrating thoracic trauma can cause major injuries including injury to the heart (eg, laceration causing cardiac tamponade), major vessels (eg, aorta or great vessels), pulmonary parenchyma or pulmonary arteries (eg, contusion, pneumothorax or hemothorax, avulsion), tracheobronchial tree, esophagus, diaphragm, or chest wall (eg, rib fractures, flail chest, open chest wound). This topic will review the anesthetic management of patients with traumatic injuries to these intrathoracic structures and/or the chest wall.
Mechanisms of injury to the chest wall and intrathoracic structures, initial evaluation, resuscitation, and management of these life-threatening cardiothoracic injuries are discussed elsewhere:
●(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".)
●(See "Resuscitative thoracotomy in adults: Technique".)
●(See "Endovascular methods for aortic control in trauma".)
Management of specific injuries is reviewed in separate topics:
●(See "Overview of blunt and penetrating thoracic vascular injury in adults".)
●(See "Management of blunt thoracic aortic injury".)
●(See "Management of cardiac injury in severely injured patients".)
●(See "Pulmonary contusion in adults".)
●(See "Overview of esophageal injury due to blunt or penetrating trauma in adults".)
●(See "Recognition and management of diaphragmatic injury in adults".)
Anesthetic considerations that are generally applicable to all trauma patients are reviewed separately. (See "Anesthesia for adult trauma patients".)
INITIAL TRAUMA APPROACH
Hemodynamically unstable patients — Initial anesthetic management of a hemodynamically unstable trauma patient is discussed separately. (See "Anesthesia for adult trauma patients", section on 'Patient stabilization and goals'.)
After thoracic trauma, initial resuscitation and management strategies 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 and algorithm 2) [1,2]. In particular, life-threatening issues such as injury leading to an open airway injury or 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" considerations (eg, a tension pneumothorax should be treated before performing endotracheal intubation since pressure ventilation following intubation will exacerbate a pneumothorax).
In rare cases, emergency thoracotomy may be performed in the emergency department (ED) if expertise is available. Indications and techniques are discussed separately. (See "Resuscitative thoracotomy in adults: Technique" and "Initial evaluation and management of penetrating thoracic trauma in adults", section on 'Role of emergency department thoracotomy'.)
If feasible, focused assessment with sonography for trauma (FAST) is performed to assess the nature and extent of the injuries, including assessment for pneumothorax or hemopericardium with cardiac tamponade or hemothorax [3]. (See "Emergency ultrasound in adults with abdominal and thoracic trauma" and "Overview of perioperative diagnostic uses of ultrasound", section on 'Determining causes of hypotension'.)
In an intubated patient, preoperative and/or intraoperative transesophageal echocardiography (TEE) examination can be used for monitoring or to rapidly diagnose unexplained hemodynamic instability due to an issue such as traumatic aortic rupture, aortic dissection, pericardial fluid, left pleural effusion, severe hypovolemia, or severe right ventricular dysfunction due to myocardial contusion [4-7]. For diagnosis of certain entities such as aortic rupture or dissection, TEE is superior to transthoracic echocardiography (TTE) [4,5]. (See "Overview of perioperative diagnostic uses of ultrasound", section on 'Transesophageal echocardiography' and "Intraoperative rescue transesophageal echocardiography (TEE)".)
Hemodynamically stable patients — Patients who are hemodynamically stable without a life-threatening airway, cardiac, pulmonary, or other vital organ injuries are typically transported to diagnostic imaging suites such as computed tomography (CT) before transport 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:
It is critically important to continue vigilant monitoring during transport and performance of imaging studies. Potentially lethal injuries may not be recognized or immediately apparent during initial assessment. Examples include pneumothorax, hemothorax, pulmonary contusion, cardiac contusion, tracheobronchial injury, diaphragmatic injury, esophageal rupture, or contained aortic disruption.
INTRAOPERATIVE ANESTHETIC MANAGEMENT —
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 1) [8,9]. (See "Anesthesia for adult trauma patients", section on 'Patient stabilization and goals'.)
Airway management — 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 3). Details are discussed in separate 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 anatomically difficult airway for general anesthesia in adults".)
Specific challenges that may be encountered after thoracic trauma include:
●Airway or upper chest injuries.
●Presence of a cervical collar.
●Significant hypotension and/or bradycardia that may develop shortly after endotracheal intubation and initiating positive pressure ventilation, indicating that a tension pneumothorax may be present. The surgeon is notified immediately since a low threshold for presumptive treatment is appropriate. (See 'Treatment of pneumothorax' below.)
●Need for immediate lung isolation in patients with massive hemoptysis, in order to prevent continued soiling of the healthy lung with blood from the injured lung. Options include a double-lumen endotracheal tube (DLT), a single-lumen endotracheal tube (ETT) plus a bronchial blocker, or a single-lumen ETT with deliberate endobronchial placement, as discussed separately. (See "Techniques to achieve lung isolation during general anesthesia".)
Induction and maintenance of general anesthesia — Induction and maintenance of general anesthesia in adult trauma patients are discussed in a separate topic. (See "Anesthesia for adult trauma patients", section on 'Induction' and "Anesthesia for adult trauma patients", section on 'Maintenance'.)
Intravascular access — Two large-bore peripheral intravenous (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. Central venous access, venous cutdown, and intraosseous access are alternative techniques when adequate peripheral venous access cannot be obtained. In general, IV access in the arms or neck is preferable to IV access below the diaphragm in patients with thoracic trauma. Intraosseous access in the humerus is similarly preferable to other sites. (See 'Monitoring' below and "Anesthesia for adult trauma patients", section on 'Intravascular access and monitoring'.)
Monitoring
●Arrhythmia monitoring and management – 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 "Perioperative arrhythmias" and "Advanced cardiac life support (ACLS) in adults", section on 'Management of specific arrhythmias'.)
●Invasive hemodynamic monitoring - Hemodynamic instability may occur due to arrhythmias, cardiac injury (eg, tamponade, contusion) or bleeding from the major vasculature (eg, aorta, pulmonary, arch vessels).
•Intra-arterial monitoring of blood pressure - Any surgical intervention for major traumatic cardiovascular or pulmonary 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 the placement of a left radial or femoral arterial catheter as well.
•Central venous pressure (CVP) – Continuous monitoring of CVP can be helpful in some patients (eg, a rising CVP indicates possible cardiac tamponade). However, the utility of CVP monitoring has been largely supplanted by arterial waveform analysis (despite limitations in an open chest) as well as by focused ultrasonography and transesophageal echocardiography (TEE). (See "Overview of perioperative diagnostic uses of ultrasound" and "Intraoperative transesophageal echocardiography for noncardiac surgery".)
•TEE – If acute, persistent, or life-threatening circulatory instability is present, intraoperative TEE is typically used to diagnose the cause (ie, "rescue echo") and to direct specific treatment. (See "Intraoperative rescue transesophageal echocardiography (TEE)".)
Hemodynamic management — Inotropic (eg, epinephrine) and/or vasopressor (eg, norepinephrine or vasopressin) support may be temporarily necessary to maintain cardiac output and blood pressure (table 2), particularly in patients with cardiac tamponade or severe myocardial contusion after blunt trauma [10]. Hypotensive resuscitation (ie, permissive hypotension), with a systolic blood pressure goal of 80 to 90 mmHg, is often employed in trauma patients with multiple injuries, unless there is concurrent brain trauma. Details regarding hemodynamic management of trauma patients are described separately. (See "Anesthesia for adult trauma patients", section on 'Hemodynamic management'.)
It is critically important to recognize and treat hypovolemia due to bleeding as the likely primary cause of hemodynamic instability in many chest trauma patients (see 'Fluid management' below). Generally, vasopressor and inotropic support play a secondary role in managing hypotension in this setting. Decisions regarding transfusion for significant bleeding are discussed in separate topics. (See "Intraoperative transfusion and administration of clotting factors" and "Massive blood transfusion", section on 'Trauma'.)
Fluid management — After initial resuscitation and achievement of hemodynamic stability, administration of fluids should be judicious to minimize edema formation in injured lung tissue. Evidence supporting these principles for fluid management during elective thoracic surgical procedures is discussed in a separate topic. (See "Anesthesia for open pulmonary resection", section on 'Fluid and hemodynamic management'.)
Dynamic assessments are typically employed to predict fluid responsiveness (improvement in cardiac output; eg, arterial waveform analysis), rather than older static measurements such as CVP. (See "Intraoperative fluid management", section on 'Dynamic parameters to assess volume responsiveness'.)
Ventilation management — Lung-protective ventilation strategies are always employed, and may be especially important after blunt thoracic injury with pulmonary contusion. Details are discussed in a separate topic. (See "Anesthesia for adult trauma patients", section on 'Lung-protective ventilation'.)
In patients with right ventricular contusion, mechanical ventilation is adjusted to minimize mean airway pressure, while high inspiratory pressures and high levels of positive end-expiratory pressure are avoided if possible [11]. (See "Anesthesia for noncardiac surgery in patients with pulmonary hypertension or right heart failure", section on 'Management of ventilation'.)
Lung isolation with one lung ventilation (OLV) may be necessary to complete portions of the planned thoracic surgical procedure. Techniques to accomplish lung isolation and principles of OLV are discussed in separate topics. (See "Techniques to achieve lung isolation during general anesthesia" and "Intraoperative one-lung ventilation".)
Emergence — The decision to extubate the patient at the end of the procedure depends on the degree of ventilatory support that is necessary, hemodynamic stability, extent of the traumatic injuries sustained, the surgical procedure that was performed, and whether additional surgical procedures will soon be necessary.
ANESTHETIC CONSIDERATIONS FOR SPECIFIC PROCEDURES
Treatment of pneumothorax — Air can enter the pleural space after either blunt or penetrating thoracic trauma. Although an open pneumothorax can occur, most commonly pneumothorax results from an injury to the lung parenchyma, trachea, or bronchi. Suspicion of a pneumothorax is generally confirmed with chest radiography (CXR) or focused sonography for trauma (FAST) examination. However, when air in the pleural space is under pressure, venous return is compromised leading to hemodynamic instability. In such cases, immediate treatment is indicated before any imaging studies are performed. (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'.)
Tube thoracostomy is performed if expertise and equipment are immediately available, but needle decompression may be used as a temporizing measure. Indications and specific techniques for these procedures are described in other topics:
●(See "Thoracostomy tubes and catheters: Placement techniques and complications", section on 'Techniques'.)
In patients with a small conservatively treated or previously undiagnosed pneumothorax, a tension pneumothorax may develop, during endotracheal intubation and initiation of positive pressure ventilation. Thus, clear communication with the anesthesia team regarding possible presence of a pneumothorax is critical [12-14]. Also, anesthesiologists should be aware that hypotension and hypoxia occurring in a thoracic trauma patient immediately after intubation and initiation of controlled ventilation may indicate development of tension pneumothorax. Hemodynamic deterioration develops due to decreased venous return, mediastinal shift, and profound decreases in cardiac output. Tracheal deviation and unilateral breath sounds may also be evident in patients with tension pneumothorax.
Treatment of hemothorax, cardiothoracic, and vascular injuries — Blood can enter the pleural space after traumatic thoracic injury from lacerations to the pulmonary parenchyma, injury to an intercostal artery or internal thoracic (mammary) artery, a great vessel, or the heart. Any patient with a penetrating wound to the chest, back, neck, or abdomen may have injuries to any of these structures, and may develop hemorrhagic shock [1,14]. Similarly, patients involved in high-energy blunt trauma as well as deceleration injury are at significant risk for injury to the aorta (often at the ligamentum arteriosum), cardiac contusion, and tamponade. Other coexisting injuries to the brain, spine, and limbs can obscure the clinical picture after blunt trauma [2]. (See "Initial evaluation and management of penetrating thoracic trauma in adults", section on 'Hemothorax and vascular injury' and "Initial evaluation and management of blunt thoracic trauma in adults".)
●Tube thoracostomy – Small hemothoraces are more common with variable clinical presentations. Imaging modalities include assessment with sonography (ie, FAST) examination, CXR, and CT imaging. Indications and techniques for thoracostomy tube placement to treat hemothorax are described in other topics:
•(See "Initial evaluation and management of blunt thoracic trauma in adults", section on 'Hemothorax'.)
Patients who have persistent CXR opacities after initial tube thoracostomy may have retained hemothorax requiring surgical management [15]. 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) [14]. Anesthetic management for thoracic VATS procedures is discussed separately. (See "Anesthesia for video-assisted thoracoscopic surgery (VATS) for pulmonary resection".)
●Emergency thoracotomy – Drainage of large amounts of blood upon placement of a chest tube or significant ongoing bleeding from the tube suggests a major cardiovascular injury with hemorrhage that is unlikely to stop without emergency surgical intervention. Patients who are hemodynamically unstable after thoracic trauma despite appropriate resuscitation efforts require emergency surgical exploration in the operating room (OR). In rare cases, a thoracotomy may be performed in the emergency department (ED) as a life-saving measure. (See "Resuscitative thoracotomy in adults: Technique".)
Blood and vasoactive agents should be immediately available, and the anesthesiologist should be prepared to provide lung isolation if indicated. (See "Anesthesia for adult trauma patients", section on 'Intraoperative management of hemorrhagic shock' and "Techniques to achieve lung isolation during general anesthesia".)
Intraoperative surgical repair of myocardial injuries typically involves use of cardiopulmonary bypass (CPB). Details regarding anesthetic management of cardiac or major vascular surgery with CPB are discussed in other topics:
•(See "Anesthesia for cardiac surgery: General principles".)
•(See "Initiation of cardiopulmonary bypass".)
•(See "Management of cardiopulmonary bypass".)
•(See "Weaning from cardiopulmonary bypass".)
•(See "Intraoperative problems after cardiopulmonary bypass".)
•(See "Anesthesia for aortic surgery with hypothermia and elective circulatory arrest in adult patients".)
•(See "Anesthesia for open descending thoracic aortic surgery".)
For some penetrating cardiac injuries, surgical repair without the use of CPB may be possible, thereby avoiding systemic anticoagulation in a patient who may have several major traumatic injuries [16]. In such cases, the surgeon may request administration of adenosine to provide 15 or 20 seconds of asystole to facilitate cardiac repair [17]. (See "Management of cardiac injury in severely injured patients", section on 'Definitive repair of cardiac injuries'.)
●Use of resuscitative endovascular balloon occlusion of the aorta (REBOA) – In rare patients, REBOA may be selected instead of resuscitative thoracotomy as a temporizing measure to support vital organ perfusion, decrease the amount of bleeding distal to the occluded site, and provide a window of opportunity for resuscitation and definitive hemorrhage control (figure 1) (see "Endovascular methods for aortic control in trauma"). Ideally, this is performed in a hybrid OR suite but can be performed in the ED on rare occasions. Anesthetic management during REBOA is discussed separately. (See "Anesthesia for adult trauma patients", section on 'Resuscitative endovascular balloon occlusion of the aorta'.)
Surgical drainage of cardiac tamponade — Cardiac tamponade is usually caused by a penetrating thoracic injury. 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. Cardiac tamponade may also occur after blunt chest trauma, most commonly due to rupture of the right atrial appendage. (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. Severe hypotension becomes evident once the volume of blood trapped in the pericardial sac increases enough to compress the heart and compromise cardiac output [18]. The presence of symptomatic cardiac tamponade mandates surgical intervention. Most patients are moved urgently to the OR for drainage of the pericardium through either a subxiphoid window, median sternotomy, or thoracotomy depending on associated thoracic injuries. Emergency pericardiocentesis and placement of a catheter may be necessary in some hemodynamically unstable patients. Patients who are not in extremis are evaluated with FAST or transesophageal echocardiography (TEE), either in the ED or the OR. (See "Cardiac tamponade" and "Emergency ultrasound in adults with abdominal and thoracic trauma", section on 'Pericardial and limited cardiac examination' and "Anesthesia for patients with pericardial disease and/or cardiac tamponade", section on 'Assessing urgency'.)
Details regarding anesthetic management of patients with pericardial tamponade are noted in the algorithm (algorithm 4) and are discussed in detail in a separate topic. (See "Anesthesia for patients with pericardial disease and/or cardiac tamponade".)
Further details regarding surgical treatment options for cardiac tamponade are discussed in separate topics:
●(See "Pericardial effusion: Approach to management".)
●(See "Emergency pericardiocentesis".)
●(See "Management of cardiac injury in severely injured patients".)
Repair of 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 (see 'Airway management' above) [19-22]. Most injuries occur within 2 cm of the carina, owing to the rapid deceleration of the relatively mobile lungs against a fixed carina, more often on the right side due to a shorter right mainstem bronchus and a heavier/larger right lung. Coexisting injuries are common, including pulmonary contusions, chest wall injuries, and fractures of the first rib, clavicle, and sternum. (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 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 attempts to accomplish 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'.)
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 since the goal is to isolate the injured bronchus from positive pressure ventilation, which may cause a tension pneumothorax. A large air leak may cause difficulty in providing adequate ventilation after successful tracheal intubation. The American Society of Anesthesiologists Committee on Trauma and Emergency Preparedness has developed guidance for these situations (algorithm 3 and table 3 and table 4) [23], and details are discussed in separate 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 anatomically difficult airway for general anesthesia in adults".)
Definitive diagnosis of tracheobronchial injuries is typically made with the aid of a flexible intubating bronchoscope (FIS) during placement of an endotracheal tube (ETT), or during surgical exploration [20]. Notably, attempts at blind instrumentation can be disastrous [24]. In one series, maneuvers necessary to secure the airway included FIS, creation of a surgical airway, or creation of a temporary airway through the wound [19]. The goal is to place the cuff of the ETT beyond the site of injury to protect the site from exposure to positive pressure ventilation, as described above (see 'Airway management' above). In some cases, other measures to secure the airway are necessary, including thoracotomy, jet ventilation via intrabronchial catheters, cross-field ventilation (with direct intubation of the main conducting airway distal to the injured tracheal area), or extracorporeal membrane oxygenation [25-27].
Emergency surgical repair is necessary in patients with ongoing risk for airway obstruction, massive air leak, or mediastinitis [28]. Most patients undergo endobronchial stenting, primary tracheal repair, and, in some cases, lung resection. (See "Identification and management of tracheobronchial injuries due to blunt or penetrating trauma".)
Airway and anesthetic management techniques during procedures for tracheal repair are discussed in a separate topic. (See "Anesthesia for tracheal resection and reconstruction", section on 'Open tracheal resection and reconstruction'.)
Repair of esophageal injury — Emergency surgery is necessary for patients with esophageal injury. (See "Overview of esophageal injury due to blunt or penetrating trauma in adults".)
Anesthetic management for the repair of esophageal injury is discussed separately. (See "Anesthesia for esophagectomy and other esophageal surgery", section on 'Repair of esophageal perforation or rupture'.)
Treatment of complicated rib fractures — Rib fractures are present in approximately ten percent of patients with chest wall trauma [29]. They are a marker for more severe injuries and are associated with significant morbidity and mortality, particularly in older patients [30]. (See "Initial evaluation and management of chest wall trauma in adults".)
For most patients with uncomplicated rib fractures, multimodal pain therapy is the primary treatment, rather than a surgical procedure. Adequate pain control is important 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. (See "Inpatient management of traumatic rib fractures and flail chest in adults", section on 'Pain control'.)
Selected patients may benefit from surgical rib fracture fixation, particularly those with multiple severe rib fractures or flail chest (figure 2) [31]. Adverse physiologic effects of the resulting paradoxical movement of a flail segment include inefficient ventilation, hypoventilation, atelectasis, pulmonary shunt, ventilation-perfusion mismatch, and hypoxemia. After endotracheal intubation, subsequent positive pressure ventilation eliminates the mechanically discordant movement of the chest wall caused by the flail segment. Noninvasive ventilation has also been employed to minimize the sequelae of paradoxical movements in selected patients [32]. Flail chest injuries are often associated with coexisting lung lacerations with pneumothorax or hemothorax, pulmonary contusion (see "Pulmonary contusion in adults"), or other injuries to thoracic and extrathoracic structures.
Rib fixation is typically performed after initial management of coexisting thoracic injuries in patients with severe rib fractures, and for patients who are refractory to pain management strategies or those with impending or actual respiratory failure [31,33]. Usually, there is no need for intraoperative lung isolation during the procedure. Details regarding surgical techniques are discussed in a separate topic. (See "Surgical management of severe rib fractures".)
POSTOPERATIVE PAIN MANAGEMENT —
Most patients with blunt or penetrating cardiac injury require at least 24 hours of monitoring in an intensive care unit even if there were no other major traumatic injuries. At the author's institution, criteria for intensive care unit (ICU) admission include age >45 years with thoracic trauma involving ≥4 rib fractures or age >65 with ≥2 rib fractures. Care includes monitoring for the possibility of arrhythmias and myocardial dysfunction and ensures optimal pulmonary toilet and pain control.
Providing optimal analgesia for patients with painful traumatic thoracic injuries may improve outcomes. General goals include improved analgesia, reduced opioid dosing to achieve effective analgesia, and decreased risk of opioid-related side effects. A multimodal approach is employed (ie, a combination of analgesics and techniques, each with a different mechanism of action within the central or peripheral nervous system) [34-36]. This approach typically includes intravenous (IV) opioid analgesics, nonopioid IV agents, and regional analgesic techniques. However, the specific strategies selected for an individual patient depend on the location and extent of thoracic and other traumatic injuries, as well as level of consciousness, hemodynamic stability, need for controlled mechanical ventilation, and whether hemostasis has been achieved.
Intravenous opioid and nonopioid agents
●Opioid analgesics – IV opioids are 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 [29,30,37,38]. When feasible, IV opioids are administered via methods allowing patient-controlled analgesia (PCA) to minimize these risks. Further discussion of uses, benefits, and adverse effects of IV opioids in critically ill patients is available elsewhere. (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 may include ketorolac, other nonsteroidal anti-inflammatory drugs, and acetaminophen, as discussed separately. (See "Pain control in the critically ill adult patient", section on 'Choosing a nonopioid'.)
Regional analgesic techniques — The anesthesia service is often consulted for placement of a regional anesthetic block if PCA with an IV opioid supplemented with IV ketorolac does not provide adequate postoperative analgesia, particularly if the patient has poor cough or incentive spirometry performance [39]. Although many options are available, we typically select continuous infusions via a thoracic paravertebral block (TPVB) catheter or thoracic epidural analgesia (TEA) as the first-line regional analgesic modality after thoracic trauma in hemodynamically stable patients with painful thoracotomy incision(s) [35,40-42]. Regional analgesia with either of these techniques has been associated with a 35 percent reduction in delirium in older adults after thoracic trauma that included multiple rib fractures [43]. Further discussion relevant for patients with similar injuries is available in other topics. (See "Anesthesia for open pulmonary resection", section on 'Choice of technique' and "Inpatient management of traumatic rib fractures and flail chest in adults", section on 'Regional anesthesia'.)
Paravertebral or epidural analgesia
●Thoracic paravertebral blocks – The TPVB technique is a common first-line regional analgesic technique in the setting of thoracotomy or blunt thoracic trauma [44,45]. TPVB involves blockade of the intercostal nerve and its dorsal ramus as well as the sympathetic chain, producing a dense sensory and sympathetic block [44]. (See "Thoracic paravertebral block procedure guide".)
Compared with TEA, catheter-based TPVB 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 [45-52]. The lower risk of adverse effects may be due to the unilateral placement of a TPVB (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 'Thoracic paravertebral block'). Also, TPVB catheter placement may be safer than epidural catheter placement in patients who are sedated or for those who require mechanical ventilation [35,53].
For these reasons, use of the TPVB technique has increased in thoracic trauma patients (either continuous infusion of local anesthetic or a single shot) [44,45]. Small studies in patients with multiple fractured ribs have noted benefits after placement of a TPVB (eg, improved pain scores, bedside spirometry measurements, and arterial blood gases, as well as reduced analgesic requirements [54,55]. 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 TPVB, with no differences noted for outcomes including mortality, duration of mechanical ventilation, development of pneumonia, and hospital length of stay [42]. Another observational study in 290 consecutive patients with rib fractures noted that TPVB placed with ultrasound guidance resulted in similar safety and efficacy compared with the use of systemic analgesia, with a nonsignificant trend toward lower mortality [56]. However, one small randomized trial has directly compared TEA versus TPVB techniques in such patients [45].
The technique for placement of a TPVB block is described separately. Placement is relatively easy for experienced clinicians, although difficulty with threading the catheter into the paravertebral space occasionally occurs [54,57]. Ultrasound-guided techniques may be used to improve ease and safety of TPVB placement (picture 1 and picture 2). (See "Thoracic paravertebral block procedure guide".)
Challenges for TPVB use in the setting of thoracic trauma include lack of familiarity with the technique among anesthesiologists. Also, nerve blockade with TPVB 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 TPVB 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 [54], and seizure activity due to local anesthetic toxicity occurred in one patient [45]. In other settings, pneumothorax, accidental vascular or dural puncture, and accidental placement of the catheter in the pleural space have been reported [54,58-60].
●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 [35,61]. (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 [46]. Compared with systemic analgesics, use of TEA results in less sedation; thus, patients can participate in pulmonary toilet [62]. Use of TEA increases FRC, vital capacity, tidal volume, and lung compliance; decreases the movement of flail segments; and increases PaO2 [53,63,64]. 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 [65]. 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 [66], larger tidal volume, fewer days on mechanical ventilation, fewer tracheostomies, and shorter ICU and hospitalization stays when TEA was used [63]. 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 [67]. (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. Trauma-associated coagulopathy may increase the risk of epidural hematoma. 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 [62]. (See "Overview of neuraxial anesthesia", section on 'Adverse effects and complications'.)
Other regional anesthetic blocks
●Erector spinae plane block – Use of erector spinae plane (ESP) blocks has been increasing for thoracic trauma patients, although data regarding efficacy are limited [41,68,69]. The ESP block is also 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 (SAP) block [41]. Furthermore, this block is an attractive alternative to TEA for patients at risk for hypotension, and for those with bony injury to the thoracic spine (typically a contraindication for neuraxial techniques). In addition, an ESP block is a good alternative to TEA or TPVB in patients with coagulation abnormalities [70,71]. Risks for pneumothorax or neurovascular injury are low compared with TEA or TPVB. Since an ESP block is a plane block, catheters may be left in place, although periodic large volume boluses may be necessary to achieve adequate analgesia.
The ESP block is typically performed in the sitting position using ultrasound guidance [40]. Further details regarding placement are available in a separate topic. (See "Erector spinae plane block procedure guide".)
●Serratus anterior plane block – Serratus anterior plane (SAP) block is another technique for treatment of pain after thoracotomy or blunt thoracic injury that may have more efficacy in patients with anterolateral compared with posterior rib fractures [40,41,72-76]. This technique offers a less invasive approach in patients with rib fractures who have contraindications to more invasive techniques [77,78]. The SAP 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) [40]. Further details regarding placement are available in a separate topic. (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 [40,53], as well as after thoracotomy procedures (figure 3 and figure 4 and image 2) [79,80]. 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 [53]. Further discussion is available in other topics. (See "Thoracic nerve block techniques", section on 'Intercostal nerve block' and "Inpatient management of traumatic rib fractures and flail chest in adults", section on 'Intercostal nerve blocks'.)
Advantages of intercostal nerve blocks include improvement in peak expiratory flow rate as well as arterial oxygen and carbon dioxide tensions [81-83]. 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 TPVB.
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 [35,84,85]. 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 [86]) 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 [86].
●Midpoint transverse process to pleura block – The midpoint transverse process to pleura (MTP) regional anesthetic block has been used as an alternative to TPVB [87,88]. The MTP block is thought to act via paravertebral spread through septations and fenestrations in the superior costotransverse ligament [89], as well as medial to the free edge of the superior costotransverse ligament. The paravertebral spread ideally would increase the efficacy of the block while limiting the potential complications of TPVB such as pleural puncture, vascular puncture and hypotension from epidural spread or even intrathecal spread [90]. Also, since MTP is a peripheral nerve block, there is less concern in patients receiving anticoagulants compared with TPVB. (See "Neuraxial anesthesia/analgesia techniques in the patient receiving anticoagulant or antiplatelet medication".)
●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 [83,91]. This technique is rarely used now due to development of newer alternatives to epidural anesthesia (eg, ESP or SAP blocks) that also have little hemodynamic sequelae [41].
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 approach – Initial resuscitation and management strategies after thoracic trauma for hemodynamically unstable patients are noted in the algorithms (algorithm 1 and algorithm 2). (See 'Hemodynamically unstable patients' above and "Anesthesia for adult trauma patients", section on 'Patient stabilization and goals'.)
Hemodynamically stable patients may be transported first to a diagnostic imaging suite before any surgical procedure. Ongoing vigilant monitoring is critically important during imaging since potentially lethal injuries may not be immediately recognized. (See 'Hemodynamically stable patients' above.)
●Intraoperative anesthetic management
•Airway management – Guidance from the American Society of Anesthesiologists Committee on Trauma and Emergency Preparedness for difficult airway management after traumatic airway injury or obstruction is useful (algorithm 3). (See 'Airway management' above.)
•Induction and maintenance – Induction and maintenance of general anesthesia in trauma patients are discussed separately. (See "Anesthesia for adult trauma patients", section on 'Induction' and "Anesthesia for adult trauma patients", section on 'Maintenance'.)
•Intravascular access – Two large-bore peripheral intravenous (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 vasoactive and anesthetic agents. IV access and arterial pressure monitoring on the contralateral side of unilateral major injuries is prudent. (See 'Intravascular access' above.)
•Monitoring - Hemodynamic instability may occur due to arrhythmias, cardiac injury (eg, tamponade, contusion) or bleeding from the major vasculature (eg, aorta, pulmonary, arch vessels). (See 'Monitoring' above.)
-Arrhythmia monitoring and management – Transcutaneous pacing/defibrillation pads should be placed prior to induction of anesthesia since hemodynamically unstable arrhythmias may occur after blunt cardiac injury.
-Invasive cardiovascular monitoring – An intra-arterial catheter is placed as soon as possible, ideally prior to induction. Intraoperative use of transesophageal echocardiography (TEE) is typically used to diagnose the cause of acute, persistent, or life-threatening circulatory instability, as discussed separately. (See "Intraoperative rescue transesophageal echocardiography (TEE)".)
•Hemodynamic management – Inotropic (eg, epinephrine) and/or vasopressor (eg, norepinephrine or vasopressin) support is often necessary to maintain cardiac output and blood pressure, particularly in patients with cardiac tamponade or severe myocardial contusion (table 2). Hypovolemia due to bleeding must be recognized and treated. (See 'Monitoring' above.)
•Fluid management – Decisions regarding transfusion for significant bleeding are discussed in separate topics. (See "Intraoperative transfusion and administration of clotting factors" and "Massive blood transfusion", section on 'Trauma'.)
After initial resuscitation, administration of fluids should be judicious to minimize edema formation in injured lung tissue; the evidence for best practice is discussed separately. (See "Anesthesia for open pulmonary resection", section on 'Fluid and hemodynamic management'.)
•Ventilation management – Lung-protective ventilation strategies are used. (See "Anesthesia for adult trauma patients", section on 'Lung-protective ventilation'.)
Lung isolation with one lung ventilation (OLV) may be necessary. Techniques and principles are discussed in separate topics. (See "Techniques to achieve lung isolation during general anesthesia" and "Intraoperative one-lung ventilation".)
•Emergence – Decisions to extubate at the end of the procedure depend on the degree of ongoing ventilatory support, hemodynamic stability, the extent of traumatic intrathoracic and other injuries, the surgical procedure initially performed, and whether additional procedures are likely. (See 'Emergence' above.)
●Specific surgical procedures – Anesthetic and surgical goals vary for the treatment of specific traumatic thoracic injuries:
•Pneumothorax – (See 'Treatment of pneumothorax' above.)
•Hemothorax, cardiothoracic, and thoracic vascular injuries – (See 'Treatment of hemothorax, cardiothoracic, and vascular injuries' above.)
•Cardiac tamponade (algorithm 4) – (See 'Surgical drainage of cardiac tamponade' above and "Anesthesia for patients with pericardial disease and/or cardiac tamponade", section on 'Treatment of pericardial effusion and/or tamponade'.)
•Tracheobronchial injury – (See 'Repair of tracheobronchial injury' above and "Anesthesia for tracheal resection and reconstruction".)
•Esophageal injury – (See 'Repair of esophageal injury' above and "Anesthesia for esophagectomy and other esophageal surgery", section on 'Repair of esophageal perforation or rupture'.)
•Rib fractures (See 'Treatment of complicated rib fractures' above and "Inpatient management of traumatic rib fractures and flail chest in adults" and "Surgical management of severe rib fractures".)
●Postoperative pain management - Specific strategies depend on the location and extent of thoracic and other traumatic injuries, as well as level of consciousness, hemodynamic stability, need for controlled mechanical ventilation, and whether hemostasis has been achieved.
•Systemic analgesics – IV opioids are administered via patient-controlled analgesia (PCA) as a first-line pain management modality in conscious patients. Nonopioid analgesic agents (eg, ketorolac, other nonsteroidal anti-inflammatory agents, acetaminophen) may be employed as adjuncts. (See 'Intravenous opioid and nonopioid agents' above.)
•Regional anesthetic techniques – In hemodynamically stable patients with painful thoracotomy incision(s), we suggest thoracic epidural analgesia (TEA) or a thoracic paravertebral block (TPVB) with continuous infusion of analgesic agents as the first-line regional analgesic modality (Grade 2C). Indirect evidence supporting this approach is discussed in a separate topic. (See "Anesthesia for open pulmonary resection", section on 'Thoracic epidural analgesia' and "Anesthesia for open pulmonary resection", section on 'Thoracic paravertebral block'.)
Other regional anesthetic techniques (eg, erector spinae plane [ESP], serratus anterior plane [SAP], midpoint transverse process to pleura [MTP], or intercostal nerve blocks) are alternative options. (See 'Other regional anesthetic blocks' above.)
