Thoracic and abdominal trauma

Contents

Overview

Thoracic injuries are present in approximately 60% of polytrauma patients and account for 25% of trauma deaths. Abdominal trauma is the third leading cause of preventable trauma death, predominantly from haemorrhage. The primary and secondary surveys identify life-threatening injuries requiring immediate intervention; the majority of thoracic injuries can be managed with tube thoracostomy without surgery. Abdominal injuries require CT in stable patients; laparotomy is the immediate response to haemodynamic instability with a positive FAST scan.

Immediately Life-Threatening Thoracic Injuries

The mnemonic ATOM FC identifies the six immediately life-threatening thoracic injuries to be excluded in the primary survey:

Airway Obstruction

Managed with airway manoeuvres, adjuncts, rapid sequence intubation, or surgical airway as appropriate. See the airway management article.

Tension Pneumothorax

Air accumulates under pressure in the pleural space, collapsing the ipsilateral lung and compressing mediastinal structures — including the contralateral lung, SVC/IVC, and great veins — causing a fall in cardiac output and cardiovascular collapse.

Clinical features: Hypoxia, tracheal deviation (away from the affected side — a late sign), absent breath sounds ipsilaterally, raised JVP, haemodynamic compromise. In the intubated patient, sudden desaturation with rising ventilator pressures.

Diagnosis and treatment: Tension pneumothorax is a clinical diagnosis — do not delay treatment for imaging. Immediate needle decompression: 14G cannula in the second intercostal space, midclavicular line (or 4th/5th ICS anterior axillary line). Definitive treatment: chest drain in the safe triangle (4th/5th ICS, anterior to mid-axillary line, above the rib).

Open Pneumothorax (Sucking Chest Wound)

A chest wall defect >2/3 the diameter of the trachea allows air to enter the pleural space preferentially with each breath. Immediate treatment: occlusive dressing with a flutter valve (or improvised three-sided dressing); followed by chest drain at a separate site.

Massive Haemothorax

1500 mL blood in the pleural cavity (or >200–300 mL/hour ongoing output after chest drain insertion). Causes hypoxia and haemodynamic compromise.

Treatment: large-bore chest drain (28–32 Fr) for drainage and to allow assessment of ongoing bleeding. Autotransfusion of drained blood can be considered. Indications for thoracotomy: initial drain output >1500 mL, ongoing output >200–300 mL/hour, or haemodynamic instability despite resuscitation.

Flail Chest

Three or more adjacent ribs fractured in two or more places, creating a free-floating segment that moves paradoxically (inward with inspiration, outward with expiration) under the influence of pleural pressure changes. Respiratory failure results from the underlying pulmonary contusion (develops over 24–48 hours), pain-limited respiratory effort, and paradoxical movement.

Management: adequate analgesia (thoracic epidural is gold standard; paravertebral or serratus anterior nerve blocks are alternatives), CPAP or NIV to splint the chest and treat atelectasis, early physiotherapy. Mechanical ventilation for respiratory failure. Surgical rib fixation (surgical stabilisation of rib fractures, SSRF) is increasingly used for selected patients with severe flail segments, particularly those with uncontrolled pain or ventilator dependence.

Cardiac Tamponade

Blood in the pericardial space (or pericardial effusion) compresses the heart, reducing ventricular filling and cardiac output.

Beck's triad: Hypotension, raised JVP, muffled heart sounds. In a trauma patient, raised JVP may not be apparent if significant haemorrhage is co-existing.

Diagnosis: FAST ultrasound (pericardial effusion with right heart collapse); echo. CXR may show an enlarged cardiac silhouette in sub-acute tamponade but is usually normal in acute haemopericardium.

Management: emergency pericardiocentesis (subxiphoid approach under ultrasound guidance if possible) as a temporising measure; definitive surgical drainage (pericardiotomy, pericardial window, or thoracotomy).

Other Thoracic Injuries

Pulmonary Contusion

Direct blunt chest trauma causes haemorrhage into alveoli. CT changes develop over 12–24 hours. Risk of ARDS; manage with lung-protective ventilation. Physiotherapy and adequate analgesia are important to prevent secondary atelectasis. Restrict fluid in isolated pulmonary contusion where possible.

Blunt Traumatic Aortic Injury (BTAI)

Rapid deceleration tears the aorta, most commonly at the aortic isthmus (just distal to the left subclavian artery origin, where the mobile arch meets the relatively fixed descending aorta). Presents as a widened mediastinum on CXR; confirmed on CT angiography showing periaortic haematoma, pseudoaneurysm, intimal tear, or transection.

Grades I–IV by CT appearance. Grades II–IV require repair. Management: immediate heart rate control with IV esmolol (target HR <80 bpm, SBP 100–120 mmHg) to reduce aortic wall stress. Definitive repair: thoracic endovascular aortic repair (TEVAR) is now the preferred approach — associated with lower mortality and paraplegia rates than open surgical repair.

Cardiac Contusion

Blunt anterior chest trauma (steering wheel, direct blow). Troponin elevation and ECG abnormalities (new bundle branch block, ST changes, arrhythmias). Echo to identify wall motion abnormalities or haemodynamically significant dysfunction. Most cardiac contusions are managed supportively with ECG monitoring and haemodynamic support as required.

Diaphragmatic Rupture

Left-sided > right (right diaphragm partially protected by liver). Blunt or penetrating. May present acutely with herniation of abdominal contents into the thorax, or be delayed. Diagnosis: CXR (bowel loops in thorax, NG tube above diaphragm on left), CT. Surgical repair required; acutely may require immediate laparotomy.

Abdominal Trauma Assessment

FAST Ultrasound

Focused Assessment with Sonography in Trauma. Examines four windows for free fluid: perihepatic (Morrison's pouch), perisplenic, pelvis/pouch of Douglas, and pericardial. FAST is positive if free fluid (blood) is present. A positive FAST in a haemodynamically unstable patient mandates emergency laparotomy. A negative FAST does not exclude injury — sensitivity is approximately 70% for significant intra-abdominal injury.

CT Abdomen and Pelvis (with IV contrast)

Provides definitive characterisation of injuries and identifies the bleeding source. Reserved for haemodynamically stable patients. Allows non-operative management decisions for solid organ injuries. CT angiography identifies active arterial bleeding (blush/extravasation) amenable to embolisation.

Diagnostic Peritoneal Lavage (DPL)

Largely superseded by FAST and CT, but may be used if FAST is equivocal and CT is not possible (patient too unstable).

Indications for Emergency Laparotomy

  • Haemodynamic instability with positive FAST (blood in abdomen, cannot be stabilised)
  • Peritonitis on examination
  • Evisceration of abdominal contents
  • Diaphragmatic injury confirmed on imaging
  • Penetrating abdominal trauma with signs of peritoneal entry

Abdominal Organ Injuries

Liver

The most commonly injured solid organ in blunt abdominal trauma. AAST grades I–VI. Grades I–III (minor lacerations, no active bleeding): non-operative management (NOM) in haemodynamically stable patients; 90%+ of blunt liver injuries are managed non-operatively. Grades IV–V with active bleeding: angioembolisation if available; operative intervention if embolisation fails or patient is unstable.

Spleen

Second most commonly injured. Non-operative management is preferred for haemodynamically stable patients; angioembolisation for higher-grade injuries or active extravasation. Splenectomy for haemodynamic instability or failure of embolisation. Patients undergoing splenectomy require vaccination against encapsulated organisms (pneumococcus, Haemophilus influenzae, meningococcus) and daily penicillin prophylaxis.

Bowel and Mesenteric Injury

Predominantly from penetrating trauma or severe blunt deceleration. Bowel injury has high mortality from delay — peritonitis evolves over hours. Any penetrating abdominal trauma with peritoneal entry should prompt laparotomy. Blunt small bowel injury may be subtle on CT and requires careful clinical reassessment.

Pelvic Fractures

Unstable pelvic fractures can cause massive haemorrhage from venous plexus or arterial injury. Immediate pelvic binder reduces pelvic volume and tamponades venous bleeding. CT angiography identifies arterial injury. Angioembolisation for arterial bleeding; REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) at Zone III for uncontrolled haemorrhage. Pre-peritoneal pelvic packing as an alternative or adjunct.

Damage Control Surgery

Damage control surgery (DCS) is a staged surgical approach for physiologically compromised trauma patients in whom definitive surgery would be fatal. The lethal triad — hypothermia, acidosis, and coagulopathy — renders prolonged surgery non-survivable.

Stage 1 — Abbreviated surgery: Control haemorrhage (packing, temporary vascular shunting) and control contamination (stapling bowel ends without anastomosis). The abdomen is left open. Duration: <60–90 minutes.

Stage 2 — ICU resuscitation: Correct the lethal triad. Warm the patient (warming blankets, warm IV fluids, warmed humidified ventilator gas). Correct coagulopathy with blood products (MTP — 1:1:1 ratio plasma:platelets:packed red cells). Reverse acidosis by restoring perfusion. Vasopressors to support MAP.

Stage 3 — Definitive surgery: Return to theatre at 24–72 hours when physiology is restored. Perform definitive bowel anastomosis, fascial closure, and reconstruction.

DCS is not appropriate for all trauma patients — it carries its own complications (additional operations, infection, anastomotic failure). It is reserved for patients with haemorrhagic shock requiring ongoing resuscitation where definitive surgery would exceed physiological tolerance.

Open Abdomen and Abdominal Compartment Syndrome

Open Abdomen Management

After damage control laparotomy, the abdominal wall is left open. Negative pressure wound therapy (NPWT — vacuum-assisted closure, VAC) is applied to the wound. NPWT:

  • Removes peritoneal fluid
  • Prevents lateral retraction of the fascial edges (allowing later primary fascial closure)
  • Reduces wound infection rates compared with other temporary closure methods

The goal is early definitive fascial closure — typically within 5–7 days. Delayed closure results in loss of domain (visceral oedema, fascial retraction) and ultimately a planned ventral hernia requiring complex reconstruction.

Abdominal Compartment Syndrome (ACS)

ACS is defined as a sustained intra-abdominal pressure (IAP) >20 mmHg associated with new organ dysfunction. Measured via an indwelling urinary catheter transducer (intravesical pressure measurement with 25 mL of saline instillation, patient supine at end-expiration).

Causes: Massive fluid resuscitation causing visceral oedema, abdominal haematoma, bowel ileus, primary abdominal catastrophe (mesenteric ischaemia, pancreatitis).

Organ effects: Reduced renal perfusion (oliguria, AKI), reduced cardiac output (IVC compression, raised intrathoracic pressure), elevated ventilator pressures (diaphragm pushed up), splanchnic ischaemia.

Management: Medical temporising measures (gastric drainage, diuresis or haemofiltration for fluid removal, neuromuscular blockade to reduce abdominal wall tone, positioning). Decompressive laparotomy is the definitive treatment for IAP >25 mmHg with new organ dysfunction not responding to medical management.

Viva Questions

A trauma patient has a tension pneumothorax. How do you diagnose and treat it?

Tension pneumothorax is a clinical diagnosis and should not wait for imaging — delay is fatal. The clinical picture is of progressive respiratory deterioration and haemodynamic compromise in a trauma patient: hypoxia, absent breath sounds on the affected side, tracheal deviation away from the affected side (a late sign), raised JVP (if not masked by hypovolaemia), and falling blood pressure. In an intubated patient, the presentation is sudden desaturation, rising peak airway pressures, and haemodynamic collapse. As soon as tension pneumothorax is suspected, I would perform needle decompression immediately: a 14G cannula inserted in the second intercostal space, midclavicular line on the affected side, advanced until air escapes. A rush of air confirms the diagnosis. Some centres prefer the 4th/5th intercostal space in the anterior axillary line as the thoracic wall is thinner. Following needle decompression, which is a temporising measure only, a definitive chest drain should be inserted in the safe triangle — 4th or 5th intercostal space, anterior to the mid-axillary line, above the rib below to avoid the neurovascular bundle. Connected to an underwater seal drain. The tension pneumothorax resolves with the release of pressure; the patient's haemodynamics typically improve rapidly.

What is damage control surgery and when is it indicated?

Damage control surgery is a staged operative strategy for trauma patients who are too physiologically compromised to survive definitive surgery. The indication is a patient with haemorrhagic shock who requires operative intervention but in whom the lethal triad — hypothermia, coagulopathy, and acidosis — makes prolonged surgery lethal. In these patients, attempting a long definitive operation in a cold, coagulopathic patient results in a bleeding, acidotic, and coagulopathic death on the operating table. Instead, DCS limits initial surgery to 60–90 minutes: pack haemorrhage, control gross contamination (staple bowel ends without forming an anastomosis), and leave the abdomen open. The patient then goes directly to the ICU for stage 2: aggressive warming, blood product resuscitation in a 1:1:1 ratio (packed red cells, FFP, platelets) guided by viscoelastic testing, correction of acidosis by restoring perfusion, and vasopressor support to maintain MAP. When temperature, pH, and coagulation have normalised — typically at 24–72 hours — the patient returns to theatre for definitive surgery: fascial closure, definitive bowel anastomosis, and reconstruction. Damage control surgery is not appropriate for all trauma patients; it carries the costs of additional operations, increased infection risk, and anastomotic complications. It is reserved for patients who clearly cannot tolerate a prolonged single-stage operation.

How do you assess and initially manage a patient with blunt abdominal trauma who is haemodynamically unstable?

Haemodynamic instability in blunt abdominal trauma demands rapid parallel assessment and intervention. The first priority is simultaneous resuscitation and identification of the bleeding source. I would establish large-bore IV access, begin major haemorrhage protocol activation (1:1:1 blood products — packed red cells, FFP, platelets), and apply a pelvic binder if pelvic fracture is possible. The FAST ultrasound is the immediate investigation — it takes less than two minutes at the bedside and identifies free intraperitoneal blood (in Morrison's pouch, perisplenic space, or the pelvis) without moving the patient. A positive FAST in a patient who cannot be haemodynamically stabilised despite active resuscitation is an indication for emergency laparotomy — the source of haemorrhage is intra-abdominal and cannot be controlled without surgery. There is no role for CT in this scenario; CT is only appropriate in patients who can achieve and maintain haemodynamic stability. If the FAST is equivocal and pelvic fracture is suspected as the bleeding source, external pelvic stabilisation with a binder and — in a specialist centre — resuscitative endovascular balloon occlusion of the aorta (REBOA) at Zone III can be used to temporise while a definitive haemostasis strategy is planned. The activation of the trauma team, early anaesthetic involvement for potential emergency intubation, and clear communication with the operating theatre team should occur simultaneously with these diagnostic and resuscitative steps.