Anesthetic Management of Thoracic Trauma

  • Stephen V. Panaro
  • Tzonghuei Herb Chen


Thoracic trauma is a morbid business. The American College of Surgeons estimates it is associated with a 10% mortality [1] with 16,000 deaths annually. That represents 25% of all trauma deaths. Considering that injury is the leading cause of death from ages 1 to 45 (more than half of all deaths ages 13–32 and 80% in teenage years) [2] and the leading cause of years of life lost before 75, its impact is enormous [3]. In one analysis, if injury is taken into account, the life expectancy in the United States rockets from 19th in the developed world to first [4]. Since the vital structures in the chest are so well protected by the bony thorax, a great deal of force is required to disrupt them, and they are uncommonly injured in isolation in blunt trauma. Indeed, 70% of the time, insults to the chest are associated with multisystem injury.


Anatomy Assessment Management Echocardiography Trauma Traumatic airway Lung isolation Tracheobronchial injury 

Supplementary material

Open image in new windowFig. 51.12 Open image in new windowFig. 51.13 Open image in new windowFig. 51.14
Video 51.1

A mid-esophageal four-chamber view showing a right ventricular contusion with severe right ventricular hypokinesis (MOV 28601 kb)

Video 51.2

A mid-esophageal right ventricular inflow-outflow view showing a tricuspid valve injury (MOV 16652 kb)

Video 51.3

Color Doppler demonstrating severe tricuspid regurgitation associated with a traumatic tricuspid valve injury (MOV 7771 kb)

Video 51.4

A large traumatic pericardial effusion with right atrial systolic collapse, suggesting pericardial tamponade (MOV 16623 kb)

Video 51.5

A large traumatic pericardial effusion with right ventricular diastolic collapse, suggesting pericardial tamponade (MP4 976 kb)

Video 51.6

A view of the descending thoracic aorta demonstrating a traumatic aortic dissection with a thin intimal flap dividing the aorta into true and false lumens (MP4 873 kb)

Video 51.7

A view of the descending thoracic aorta with a “medial flap” demonstrating traumatic aortic disruption (MOV 43659 kb)

Video 51.8

A transgastric left ventricular short axis view showing severe hypovolemia (MP4 873 kb)


  1. 1.
    American College of Surgeons Committee on Trauma. Thoracic trauma. In: ATLS® program for doctors student course manual. 6th ed. Chicago: American College of Surgeons; 1997. p. 127–41.Google Scholar
  2. 2.
    Bergen G, Chen LH, Warner M, Fingerhut LA. Injury in the United States: 2007 Chartbook. Hyattsville: National Center for Health Statistics; 2008.Google Scholar
  3. 3.
    Fingerhaut LA, Warner M. Injury Chartbook. Health, United States, 1996–7. Hyattsville: National Center for Health Statistics; 1998.Google Scholar
  4. 4.
    Ohsfeldt RL, Schneider JE. The business of health. The role of competition, markets, and regulation. 1st ed. Washington DC: AEI Press; 2006.Google Scholar
  5. 5.
    American College of Surgeons Committee on Trauma. Thoracic trauma. In:ATLS® program for doctors student course manual. 9th ed. Chicago: American College of Surgeons; 2012. p. 94–112.Google Scholar
  6. 6.
    Rozycki GS, Feliciano DV, Ochsner MG, et al. The role of ultrasound in patients with possible penetrating cardiac wounds: a prospective multicenter study. J Trauma Acute Care Surg. 1999;46:543–51.CrossRefGoogle Scholar
  7. 7.
    Kirkpatrick AW, Ball CG, D’Armours SK, Zygun D. Acute resuscitation of the unstable adult trauma patient: bedside diagnosis and therapy. Can J Surg. 2008;5(1):57–69.Google Scholar
  8. 8.
    Hakuba T, Minato N, Minematsu T, Kamohara K. Surgical management and treatment of traumatic right atrial rupture. Gen Thorac Cardiovasc Surg. 2008;56(11):551–4.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Lim R, Gill IS, Temes RT, Smith CE. The use of adenosine for repair of penetrating cardiac injuries: a novel method. Ann Thoracic Surg. 2001;71:1714–5.CrossRefGoogle Scholar
  10. 10.
    Mowery NT, Gunter OL, Collier BR, Jose’J D Jr, Haut E, Hildreth A, Holevar M, Mayberry J, Streib E. Practice management guidelines for management of hemothorax and occult Pneumothorax. J Trauma Acute Care Surg. 2011;70(2):510–8.CrossRefGoogle Scholar
  11. 11.
    Clancy K, Velopulos C, Bilaniuk JW, et al. Screening for blunt cardiac injury. J Trauma Acute Care Surg. 2012;73(5):S301–6.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Karalis D, Victor M, Davis G, McAllister M, Covalesky V, Ross J, Foley R, Kerstein M, Chandrasekaran K. The role of echocardiography in blunt chest trauma. J Trauma. 1994;36(1):53–8.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Chirillo F, Totis O, Cavarzerani A, et al. Usefulness of transthoracic and transoesophageal echocardiography in recognition and management of cardiovascular injuries after blunt chest trauma. Heart. 1996;75(3):301–6.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Shanewise JS, Cheung AT, Aronson S, et al. ASE/SCA guidelines for performing a comprehensive intraoperative multiplane transesophageal echocardiography examination: recommendations of the American Society of Echocardiography Council for Intraoperative Echocardiography and the Society of Cardiovasc. Anesth Analg. 1999;89:870–84.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Poterack KA. Who uses transesophageal echocardiography in the operating room? Anesth Analg. 1995;80(3):454–8.PubMedPubMedCentralGoogle Scholar
  16. 16.
    Minhaj M, Patel K, Muzic D, et al. The effect of routine intraoperative transesophageal echocardiography on surgical management. J Cardiothorac Vasc Anesth. 2007;21(6):800–4.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Memtsoudis SG, Rosenberger P, Loffler M, et al. The usefulness of transesophageal echocardiography during intraoperative cardiac arrest in noncardiac surgery. Anesth Analg. 2006;102(6):1653–7.CrossRefGoogle Scholar
  18. 18.
    Kallmeyer IJ, Collard CD, Fox JA, Body SC, Shernan SK. The safety of intraoperative transesophageal echocardiography: a case series of 7200 cardiac surgical patients. Anesth Analg. 2001;92(5):1126–30.CrossRefGoogle Scholar
  19. 19.
    Reeves ST, Finley AC, Skubas NJ, et al. Basic perioperative transesophageal echocardiography examination: a consensus statement of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr. 2013;26:443–56.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Thys DM, Abel MD, Brooker RF, Cahalan MK, Connis RT, Duke PG, Nickinovich DG, Reeves ST, Rozner MA, Russell IA, Streckenbach SC. Practice guidelines for perioperative transesophageal echocardiography. Anesthesiology. 2010;112(5):1084–96.Google Scholar
  21. 21.
    Leichtle SW, Singleton A, Singh M, Griffee MJ, Tobin JM. Transesophageal echocardiography in the evaluation of the trauma patient: a trauma resuscitation transesophageal echocardiography exam. J Crit Care. 2017;40:202–6.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Catoire P, Orliaguet G, Liu N, et al. Systemic transoesophageal echocardiography for detection of mediastinal lesions in patients with multiple injuries. J Trauma. 1995;38(1):96–8.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Mollod M, Felner JM. Transesophageal echocardiography in the evaluation of cardiothoracic trauma. Am Heart J. 1996;132(4):841–9.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Griffee MJ, Singleton A, Zimmerman JM, Morgan DE. The effect of perioperative rescue transesophageal echocardiography on the management of trauma patients. Anesth Analg. 2016;6(12):387–90.Google Scholar
  25. 25.
    Markin NW, Gmelch BS, Griffee MJ, Holmberg TJ, Morgan DE, Zimmerman JM. A review of 364 perioperative rescue echocardiograms: findings of an anesthesiologist-staffed perioperative echocardiography service. J Cardiothorac Vasc Anesth. 2015;29(1):82–8.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Porter TR, Shillcutt SK, Adams MS, et al. Guidelines for the use of echocardiography as a monitor for therapeutic intervention in adults: a report from the American Society of Echocardiography. J Am Soc Echocardiogr. 2015;28(1):40–56.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Shillcutt SK, Markin NW, Montzingo CR, Brakke TR. Use of rapid “rescue” perioperative echocardiography to improve outcomes after hemodynamic instability in noncardiac surgical patients. J Cardiothorac Vasc Anesth. 2012;26(3):362–70.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Kaye P, O’Sullivan I. Myocardial contusion: emergency investigation and diagnosis. Emerg Med J. 2002;19(1):8–10.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Sousa RC, Garcia-Fernandez MA, Moreno M, Quero F, Torrecilla E, San Roman D, Delcan JL. Value of transesophageal echocardiography in the assessment of blunt chest trauma: correlation with electrocardiogram, heart enzymes, and transthoracic echocardiogram. Rev Port Cardiol. 1994;13(11):833–43. 807-8.PubMedPubMedCentralGoogle Scholar
  30. 30.
    Orliaguet G, Ferjani M, Riou B. The heart in blunt trauma. Anesthesiology. 2001;95:544–8.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Maenza RL, Seaberg D, D’Amico F. A meta-analysis of blunt cardiac trauma: ending myocardial confusion. Am J Emerg Med. 1996;14(3):237–41.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Yousef R, Carr JA. Blunt cardiac trauma: a review of the current knowledge and management. Ann Thorac Surg. 2014;98(3):1134–40.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Ouda A, Kappert U, Ghazy T, et al. Isolated rupture of the right upper pulmonary vein: a blunt cardiac trauma case. Ann Thorac Surg. 2011;91(4):1267–9.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Rowe SK, Porter CB. Atrial septal hematoma: two-dimensional echocardiographic findings after blunt chest trauma. Am Heart J. 1987;114(3):650–2.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Fegheli NT, Prisant LM. Blunt myocardial injury. Chest. 1995;108:1673–7.CrossRefGoogle Scholar
  36. 36.
    Shapiro M, Yanofski S, Trapp J, et al. Cardiovascular evaluation in blunt thoracic trauma using Transesophageal Echocardiography (TEE). J Trauma. 1991;31(6):835–40.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Brooks SW, Young JC, Cmolik B, et al. The use of transesophageal echocardiography in the evaluation of chest trauma. J Trauma. 1992;32(6):761–6.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Zakynthinos EG, Vassilakopoulos T, Routsi C, Roussos C, Zakynthinos S. Early- and late-onset atrioventricular valve rupture after blunt chest trauma: the usefulness of transesophageal echocardiography. J Trauma. 2002;52(5):990–6.PubMedPubMedCentralGoogle Scholar
  39. 39.
    Varahan SL, Farah GM, Caldeira CC, Hoit BD, Askari AT. The double jeopardy of blunt chest trauma: a case report and review. Echocardiography. 2006;23(3):235–9.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Bruschi G, Agati S, Iorio F, Vitali E. Papillary muscle rupture and pericardial injuries after blunt chest trauma. Eur J Cardiothorac Surg. 2001;20(1):200–2.CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Nelson M, Wells G. A case of traumatic tricuspid valve regurgitation caused by blunt chest trauma. J Am Soc Echocardiogr. 2007;20(2):198.e4–5.CrossRefGoogle Scholar
  42. 42.
    Ellis JE, Bender EM. Intraoperative transesophageal echocardiography in blunt thoracic trauma. J Cardiothorac Vasc Anesth. 1991;5(4):373–6.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Kennedy N, Ireland M, McConaghy P. Transoesophageal echocardiographic examination of a patient with venacaval and pericardial tears after blunt chest trauma. Br J Anaesth. 1995;75:495–7.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    De Maria E, Gaddi O, Navazio A, Monducci I, Tirabassi G, Guiducci U. Right atrial free wall rupture after blunt chest trauma. J Cardiovasc Med (Hagerstown). 2007;8(11):946–9.CrossRefGoogle Scholar
  45. 45.
    Nandate K, Krishnamoorthy V, McIntyre LK, Verrier ED, Mackensen GB. Gunshot-induced aorto-left atrial fistula diagnosed by intraoperative transesophageal echocardiography. Ann Thorac Surg. 2016;101(2):771–3.CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Rudski LG, Lai WW, Afilalo J, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography. J Am Soc Echocardiogr. 2010;23(7):685–713.CrossRefGoogle Scholar
  47. 47.
    Lang RM, Bierig M, Devereux RB, et al. Recommendations for chamber quantification: a report from the American Society of Echocardiography’s guidelines and standards committee and the chamber quantification writing group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr. 2005;18(12):1440–63.CrossRefGoogle Scholar
  48. 48.
    Reichert CLA, Visser CA, van den Brink RBA, et al. Prognostic value of biventricular function in hypotensive patients after cardiac surgery as assessed by transesophageal echocardiography. J Cardiothorac Vasc Anesth. 1992;6(4):429–32.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Vignon P, Gueret P, Vedrinne JM, Lagrange P, Cornu E, Abrieu O, Gastinne H, Bensaid J, Lang R. Role of transesophageal echocardiography in the diagnosis and management of traumatic aortic disruption. Circulation. 1995;92(10):2959–68.CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Vignon P, Boncoeur MP, François B, Rambaud G, Maubon A, Gastinne H. Comparison of multiplane transesophageal echocardiography and contrast-enhanced helical CT in the diagnosis of blunt traumatic cardiovascular injuries. Anesthesiology. 2001;94(4):615–22.CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    Saranteas T, Mavrogenis AF, Mandila C, Poularas J, Panou F. Ultrasound in cardiac trauma. J Crit Care. 2017;38:144–51.CrossRefPubMedPubMedCentralGoogle Scholar
  52. 52.
    Lanigan MJ, Chaney MA, Gologorsky E, Chavanon O, Augoustides JG. CASE 2 – 2014: aortic dissection: real or artifact? J Cardiothorac Vasc Anesth. 2014;28(2):398–407.CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    Ahrar K, Smith DC, Bansal RC, Razzouk A, Catalano RD. Angiography in blunt thoracic aortic injury. J Trauma. 1997;42(4):665–9.CrossRefPubMedPubMedCentralGoogle Scholar
  54. 54.
    Bansal V, Lee J, Coimbra R. Current diagnosis and management of blunt traumatic rupture of the thoracic aorta. J Vasc Bras. 2007;6(1):64–73.CrossRefGoogle Scholar
  55. 55.
    Le Bret F, Ruel P, Rosier H, Goarin JP, Riou B, Viars P. Diagnosis of traumatic mediastinal hematoma with transesophageal echocardiography. Chest. 1994;105(2):373–6.CrossRefPubMedPubMedCentralGoogle Scholar
  56. 56.
    Vignon P, Rambaud G, François B, Preux P-M, Lang RM, Gastinne H. Quantification of traumatic hemomediastinum using transesophageal echocardiography. Chest. 1998;113(6):1475–80.CrossRefPubMedPubMedCentralGoogle Scholar
  57. 57.
    Hahn RT, Abraham T, Adams MS, et al. Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. Anesth Analg. 2014;118(1):21–68.CrossRefPubMedPubMedCentralGoogle Scholar
  58. 58.
    Neskovic AN, Hagendorff A, Lancellotti P, et al. Emergency echocardiography: the European Association of Cardiovascular Imaging recommendations. Eur Heart J Cardiovasc Imaging. 2013;14(1):1–11.CrossRefPubMedPubMedCentralGoogle Scholar
  59. 59.
    Levitov A, Frankel HL, Blaivas M, et al. Guidelines for the appropriate use of bedside general and cardiac ultrasonography in the evaluation of critically ill patients—part II. Crit Care Med. 2016;44(6):1206–27.CrossRefPubMedPubMedCentralGoogle Scholar
  60. 60.
    Santoni BG, Hindman BJ, Puttit CM, Weeks JB, Johnson N, Maktabi MA, Todd MM. Manuel in-line stabilization increases pressures applied by the laryngoscope blade during direct laryngoscopy and orotracheal intubation. Anesthesiology. 2009;110:24–31.CrossRefPubMedPubMedCentralGoogle Scholar
  61. 61.
    Manoach S, Paladino L. Laryngoscopy force, visualization and intubation failure in acute trauma. Anesthesiology. 2009;110:6–7.CrossRefPubMedPubMedCentralGoogle Scholar
  62. 62.
    Rice MJ, Mancuso AA, Gibbs C, Morey TE, Gravenstein N, Deitte LA. Cricoid pressure results in compression of the postcricoid hypopharynx: the esophageal position is irrelevant. Anesth Analg. 2009;109:1546–52.CrossRefGoogle Scholar
  63. 63.
    Ovassapian A, Salem MR. Sellick’s maneuver: to do or not to do. Anesth Analg. 2009;109:1360–2.CrossRefGoogle Scholar
  64. 64.
    Lerman J. On cricoid pressure: “may the force be with you”. Anesth Analg. 2009;109:1363–6.CrossRefGoogle Scholar
  65. 65.
    Priebe HJ. Cricoid pressure: an alternative view. Semin Anesth. 2005;24(2):120–6.Google Scholar
  66. 66.
    Birenbaum A, Hajage D, Roche S, et al. Effect of cricoid pressure compared with a sham procedure in the rapid sequence induction of anesthesia: the IRIS randomized clinical trial. JAMA Surg. 2018;
  67. 67.
    Hagberg CA, Kaslow O. Difficult airway management in trauma updated by COTEP. ASA Monitor. 2014;78(9):56–60.Google Scholar
  68. 68.
    Crosby ET. Airway management in adults after cervical spine trauma. Anesthesiology. 2006;104:1293–318.CrossRefGoogle Scholar
  69. 69.
    Shatney CH, Brunner RD, Nguyen TQ. The safety of orotracheal intubation in patients with unstable cervical spine fracture or high spinal cord injury. Am J Surg. 1995;170:676–80.CrossRefPubMedPubMedCentralGoogle Scholar
  70. 70.
    Stephens CT, Kahntroff S, Dutton RP. The success of emergency endotracheal intubation in trauma patients: a 10-year experience at a major adult trauma referral center. Anesth Analg. 2009;109:866–72.CrossRefPubMedPubMedCentralGoogle Scholar
  71. 71.
    Campos JH, Hallam EA, Van Natta T, Kernstine KH. Devices for lung isolation used by anesthesiologists with limited thoracic experience. Anesthesiology. 2006;104:261–6.CrossRefGoogle Scholar
  72. 72.
    Narayanaswamy M, McRae K, Slinger P, Dugas G, Kanellakos GW, Roscoe A, Lacroix M. Choosing a lung isolation device for thoracic surgery: a randomized trial of three bronchial blockers and double lumen tubes. Anesth Analg. 2009;108:1097–01.CrossRefPubMedPubMedCentralGoogle Scholar
  73. 73.
    Ehrenfeld JM, Walsh JL, Sandberg WA. Right- and left-sided Mallinckrodt double-lumen tubes have identical clinical performance. Anesth Analg. 2008;106:1847–52.CrossRefPubMedPubMedCentralGoogle Scholar
  74. 74.
    Kemmerer WT, Eckert WG, Gathright JB, Reemtsma k CO. Patterns of thoracic injuries in fatal traffic accidents. J Trauma. 1961;1:595–9.CrossRefPubMedPubMedCentralGoogle Scholar
  75. 75.
    Kummer C, Netto FS, Rizoli S, Yee D. A review of traumatic airway injuries: potential implications for airway assessment and management. Injury Int J Care Injured. 2007;38:27–33.CrossRefGoogle Scholar
  76. 76.
    Rossbach MM, Johnson SB, Gomez MA, Sako EY, Miller L, Calhoon JH. Management of tracheobronchial injuries: a 28-year experience. Ann Thorac Surg. 1998;65:182–6.CrossRefPubMedPubMedCentralGoogle Scholar
  77. 77.
    Kisser AC, Obrien SM, Detterbeck FC. Blunt tracheobronchial injuries: treatment and outcomes. Ann Thorac Surg. 2001;71:2059–65.CrossRefGoogle Scholar
  78. 78.
    Shah AS, Forbess JM, Skaryak LA, Lilly RE, Vaslef SN, D’Amico TA. Emergent thoracotomy for airway control after intrathoracic tracheal injury. J Trauma. 2000;48(6):1163–4.CrossRefPubMedPubMedCentralGoogle Scholar
  79. 79.
    Naghibi K, Hashemi SL, Sajedi P. Anesthetic management of tracheobronchial rupture following blunt chest trauma. Acta Anaesthesiol Scand. 2003;47:901–3.CrossRefPubMedPubMedCentralGoogle Scholar
  80. 80.
    Symbas PN, Justicz AG, Ricketts RR. Rupture of the airways from blunt trauma: treatment of complex injuries. Ann Thorac Surg. 1992;54:177–83.CrossRefPubMedPubMedCentralGoogle Scholar
  81. 81.
    Shweikh AM, Nadkarni AB. Laryngotracheal separation with pneumopericardium after a blunt trauma to the neck. Emerg Med J. 2001;18:410–1.CrossRefPubMedPubMedCentralGoogle Scholar
  82. 82.
    Gómez-Caro A, Ausín P, et al. Role of conservative medical management of tracheobronchial injuries. J Trauma. 2006;61:1426–35.CrossRefPubMedPubMedCentralGoogle Scholar
  83. 83.
    Borasio P, Arissone F, Chiampo G. Post-intubation tracheal rupture. A report on ten cases. Eur J Cardiothorac Surg. 1997;12:98–100.CrossRefPubMedPubMedCentralGoogle Scholar
  84. 84.
    Parmley LF, Mattingly TW, Manion WC, Jahnke EJ Jr. Nonpenetrating traumatic injury of the aorta. Circulation. 1958;17:1086–101.CrossRefPubMedPubMedCentralGoogle Scholar
  85. 85.
    Schulman CI, Carvajal D, Lopez PP, Soffer D, Habib F, Augenstein J. Incidence and crash mechanisms of aortic injury during the past decade. J Trauma. 2007;62:664–7.CrossRefPubMedPubMedCentralGoogle Scholar
  86. 86.
    Bruno VD, Batchelor TJP. Late aortic injury: a rare complication of a posterior rib fracture. Ann Thorac Surg. 2009;87:301–3.Google Scholar
  87. 87.
    Neschis DG, Scalea TM, Flinn WR, Griffith BP. Blunt aortic injury. N Engl J Med. 2008;359:1708–16.Google Scholar
  88. 88.
    Fabian TC, Richardson JD, Croce MA, Smith JS Jr, Rodman G Jr, Kearney PA, et al. Prospective study of blunt aortic injury: multicenter trial of the American Association for the surgery of trauma. J Trauma. 1997;42:374–80.Google Scholar
  89. 89.
    Fabian TC, Davis KA, Gavant ML, et al. Prospective study of blunt aortic injury; helical CT is diagnostic and antihypertensive therapy reduces rupture. Ann Surg. 1998;227:666–76.Google Scholar
  90. 90.
    Malhotra AK, Fabian TC, Croce MA, Weinman DS, Gavant ML, Pate JW. Minimal aortic injury: a lesion associated with advancing diagnostic techniques. J Trauma. 2001;51:1042–8.Google Scholar
  91. 91.
    Hirose H, Gill IS, Malangoni MA. Nonoperative management of traumatic aortic injury. J Trauma. 2006;60:597–601.Google Scholar
  92. 92.
    Coselli JS, LeMaire SA, Köksoy C, Schmittling ZC, Curling PE. Cerebrospinal fluid drainage reduces paraplegia after thoracoabdominal aortic aneurysm repair: results of a randomized clinical trial. J Vasc Surg. 2002;35:631–9.Google Scholar
  93. 93.
    Feezor RJ, Hess PJ, Martin TD, Klodell CT, Beaver TM, Lottenberg L, Martin LC, Lee WA. Endovascular treatment of traumatic aortic injuries. J Am Coll Surg. 2009;208:510–6.Google Scholar
  94. 94.
    Lettinga-van de Poll T, Schurink GWH, DeHaan MW, Verbruggen JPAM, Jacobs MJ. Endovascular treatment of traumatic rupture of the thoracic aorta. Br J Surg. 2007;94:525–33.Google Scholar
  95. 95.
    Ehrlich MP, Rosseau H, Heijman R, Piquet P, Beregi JP, Nienaber CA, Sodeck G, Fattori R. Early outcome of endovascular repair of acute traumatic aortic injuries: the talent thoracic retrospective registry. Ann Thorac Surg. 2009;88:1258–66.Google Scholar
  96. 96.
    Reed AB, Thompson JK, Grafton CJ, Delvecchio C, Giglia JS. Timing of endovascular repair of blunt traumatic thoracic transections. J Vasc Surg. 2006;43:684–8.Google Scholar
  97. 97.
    Demetriades D, Velmahos GC, Scalea TM, et al. Operative repair or endovascular stent graft in blunt traumatic thoracic aortic injuries: results of an American association for the surgery of trauma multicenter study. J Trauma. 2008;64:561–70.Google Scholar
  98. 98.
    Demetriades D, Velmahos GC, Scalea TM, et al. Diagnosis and treatment of blunt thoracic aortic injuries: changing perspectives. J Trauma. 2008;64:1415–8.Google Scholar
  99. 99.
    Pang D, Hildebrand D, Bachoo P. Thoracic Endovascular Repair (TEVAR) versus open surgery for blunt traumatic thoracic aortic injury. Cochrane Database Syst Rev. 2015;(9):CD006642.Google Scholar
  100. 100.
    Lee AW, Matsumura JS, Mitchell RS, Farber MA, Greenberg RK, Azizzadeh A, Murad MH, Fairman RM. Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the Society for Vascular Surgery. J Vast Surg. 2011;53:187–92.CrossRefGoogle Scholar
  101. 101.
    DuBose JJ, Leake SS, Brennar M, Pasley J, O’Callaghan T, Luo-Owen X, et al. Contemporary management and outcomes of blunt thoracic aortic injury: a multi center retrospective study. J Trauma Acute Care Surg. 2015;78(2):360–9.CrossRefPubMedPubMedCentralGoogle Scholar
  102. 102.
    Devitt JH, McLean RF, Koch JP. Anaesthetic management of acute blunt thoracic trauma. Can J Anaesth. 1991;308:506–10.CrossRefGoogle Scholar
  103. 103.
    Leone M, Brégeon F, Antonini F, et al. Long term outcome in chest trauma. Anesthesiology. 2008;109:864–71.Google Scholar
  104. 104.
    Soldati G, Testa A, Silva FR, et al. Chest ultrasonography in lung contusion. Chest. 2006;130:533–8.Google Scholar
  105. 105.
    Ball CG, Ranson MK, Rodriguez-Galvez M, Lall R, Kirkpatrick AW. Sonographic depiction of posttraumatic alveolar-interstitial disease: the hand held diagnosis of a pulmonary contusion. J Trauma. 2009;66:962.Google Scholar
  106. 106.
    Hoth JJ, Stitzel JD, Gayzik S, Brownlee NA, Miller PR, Yoza BK, McCall CE, Meredith JW, Payne RM. The pathogenesis of pulmonary contusion: an open chest model in the rat. J Trauma. 2006;61:32–45.Google Scholar
  107. 107.
    Keel M, Ecknauer E, Stocker R, et al. Different pattern of local and systemic release of proinflammatory and anti-inflammatory mediators in severely injured patients with chest trauma. J Trauma. 1996;40:907–12.Google Scholar
  108. 108.
    Keel M, Trentz O. Pathophysiology of polytrauma. Injury. 2005;36:691–709.Google Scholar
  109. 109.
    Muehlstedt SG, Richardson CJ, Lyte M, Rodriguez JL. Systemic and pulmonary effector cell function after injury. Crit Care Med. 2002;30:1322–6.Google Scholar
  110. 110.
    Perl M, Gebhard F, Brückner UB, Ayala A, Braumüller C, Kinzl L, Knöferl MW. Pulmonary contusion causes impairment of macrophage and lymphocyte immune function and increases mortality associated with a subsequent septic challenge. Crit Care Med. 2005;33(6):1351–8.Google Scholar
  111. 111.
    Knöferl MW, Liener UC, Perl M, et al. Blunt chest trauma induces delayed splenic immunosupression. Shock. 2004;22:51–6.Google Scholar
  112. 112.
    Simon B, Ebert J, Bokhari F, Capella J, Emhoff T, et al. EAST practice management workgroup for pulmonary contusion-flail chest. Eastern Association for the Surgery of Trauma. 2006.
  113. 113.
    Schreiter D, Reske A, Stichert B, Seiwerts M, et al. Alveolar recruitment in combination with sufficient positive end-expiratory pressure increases oxygenation and lung aeration in patients with severe chest trauma. Crit Care Med. 2004;32(4):968–75.Google Scholar
  114. 114.
    Kelly ME, Miller PR, Greenshaw JJ, Fabian TC, Proctor KG. Novel resuscitation strategy for pulmonary contusion after severe chest trauma. J Trauma. 2003;55:94–105.Google Scholar
  115. 115.
    Jacobs JV, Hooft NM, Robinson BR, et al. The use of extracorporeal membrane oxygenation in blunt thoracic trauma: a study of the extracorporeal life support organization database. J Trauma Acute Care Surg. 2015;79(6):1049–54.CrossRefPubMedPubMedCentralGoogle Scholar
  116. 116.
    Maron BJ, Gohman TE, Kyle SB, Estes NA, Link MS. Clinical profile and spectrum of commotion cordis. JAMA. 2002;287:1142–6.Google Scholar
  117. 117.
    Link MS, Wang PJ, Pandian NG, et al. An experimental model of sudden death due to low-energy chest-wall impact (commotion cordis). N Engl J Med. 1998;338:1805–11.Google Scholar
  118. 118.
    Robert E, de la Coussaye JE, Aya AGM, Bertinchant JP, Polge A, Fabbro-Péray P, Pignodel C, Eledjam JJ. Mechanisms of ventricular arrhythmias induced by myocardial contusion. Anesthesiology. 2000;92:1132–43.Google Scholar
  119. 119.
    Sakka SG, Huettermann E, Giebe W, Reinhart K. Late cardiac arrhythmias after blunt chest trauma. Intensive Care Med. 2000;26:792–5.Google Scholar
  120. 120.
    Teixeria PG, Georgiou C, Inaba K, et al. Blunt cardiac trauma: lessons learned from the medical examiner. J Trauma. 2009;67:1259–64.Google Scholar
  121. 121.
    Sisley AC, Rozycki GS, Ballard RN, et al. Rapid detection of traumatic effusion using surgeon performed ultrasonography. J Trauma. 1998;44(2):291–6.Google Scholar
  122. 122.
    Rozycki GS, Feliciano DV, Oschner MG, et al. The role of surgeon performed ultrasound in patients with possible cardiac wounds. Ann Surg. 1996;223(6):737–44.Google Scholar
  123. 123.
    Pasquale MD, Nagy K, Clark J. Practice management guidelines for the screening of blunt cardiac injury. Eastern Association for the Surgery of Trauma. 1998. Available on URL Accessed 1/1/2010.
  124. 124.
    Christensen MA, Sutton KR. Myocardial contusion: new concepts in diagnosis and management. Am J Crit Care. 1993;2(1):28–34.Google Scholar
  125. 125.
    Lindstaedt M, Germing A, Lawo T, et al. Acute and long-term clinical significance of myocardial contusion following blunt thoracic trauma: results of a prospective study. J Trauma. 2002;52:479–85.Google Scholar
  126. 126.
    Velmahos GC, Karaiskakis M, Salim A, Toutouzas KG, Murray J, Asensio J, Demetriades D. Normal electrocardiography and serum troponin I levels preclude the presence if clinically significant cardiac injury. J Trauma. 2003;54:45–51.Google Scholar
  127. 127.
    Schultz JM, Trunkey DD. Blunt cardiac injury. Crit Care Clin. 2004;20(1):57–70.Google Scholar
  128. 128.
    Parmley LF, Manion WC, Mattingly TW. Nonpenetrating traumatic injury of the heart. Circulation. 1958;18(3):371–96.Google Scholar
  129. 129.
    Jeon Y, Ryu JH, Lim YJK, Kim CSB, Bahk JH, Yoon SZ, Choi JY. Comparative effects of vasopressin and norepinephrine after milrinone-induced hypotension in off-pump coronary artery bypass surgical patients. Eur J Cardiothoracic Surg. 2006;29(6):952–6.Google Scholar
  130. 130.
    Ziegler DW, Agarwal NN. The morbidity and mortality of rib fractures. J Trauma. 1994;37(6):975–9.CrossRefPubMedPubMedCentralGoogle Scholar
  131. 131.
    Clark GC, Schecter WP, Trunkey DD. Variables affecting outcome in blunt chest trauma: flail chest vs. pulmonary contusion. J Trauma. 1988;28:298–304.CrossRefPubMedPubMedCentralGoogle Scholar
  132. 132.
    Barnea Y, Kashtan H, shornick Y, Werbin N. Isolated rib fractures in elderly patients; mortality and morbidity. Can J Surg. 2002;45:43–6.PubMedPubMedCentralGoogle Scholar
  133. 133.
    Bulger EM, Arenson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. J Trauma. 2000;48(6):1040–7.CrossRefPubMedPubMedCentralGoogle Scholar
  134. 134.
    Simon BJ, Cushman J, Barraco R, et al. For the EAST practice management guidelines work group. Pain management guidelines for blunt thoracic trauma. J Trauma. 2005;59:1256–67.CrossRefPubMedPubMedCentralGoogle Scholar
  135. 135.
    Kasotakis G, Hasenboehler EA, Streib EW, Patel N, Patel MB, Alarcon L, Bosarge PL, Love J, Haut ER, Como JJ. Operative fixation of rib fractures after blunt trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2017;82(3):618–26.CrossRefPubMedPubMedCentralGoogle Scholar
  136. 136.
    Davignon K, Kwo J, Bigatello LM. Pathophysiology and management of the flail chest. Minerva Anestesiol. 2004;70:193–9.PubMedPubMedCentralGoogle Scholar
  137. 137.
    Roberts S, Skinner D, Biccard B, Rodseth RN. The role of non-invasive ventilation in blunt chest trauma: systemic review and meta-analysis. Eur J Trauma Emerg Surg. 2014;40:553–9.CrossRefPubMedPubMedCentralGoogle Scholar
  138. 138.
    Proctor H, London PS. The stove-in chest with paradoxical respiration. Br J Surg. 1955;42(176):622–33.CrossRefPubMedPubMedCentralGoogle Scholar
  139. 139.
    Enderson BL, Abdalla R, Frame SB, Casey MT, Gould H, Maull KI. Tube thoracotomy for occult pneumothorax; a prospective randomized study of its use. J Trauma. 1993;35:726–9.CrossRefPubMedPubMedCentralGoogle Scholar
  140. 140.
    Brasel KJ, Stafford RE, Wiegelt JA, Tenquist JE, Borgstrom DC. Treatment of occult pneumothoraces from blunt trauma. J Trauma. 1999;46:987–90.CrossRefPubMedPubMedCentralGoogle Scholar
  141. 141.
    Harcke HT, Mabry RL, Mazuchowski EL. Needle thoracentesis decompression: observations from postmortem computed tomography and autopsy. J Spec Oper Med. 2013;13:53–6.PubMedPubMedCentralGoogle Scholar
  142. 142.
    DuBose J, Inaba K, Demetriades D, Scalea TM, O’Connor J, Menaker J, Morales C, Konstantinidis A, Shiflett A, Copwood B, AAST retained hemoythroax study group. Management of post-traumatic retained hemothorax: a prospective, observational, multicenter AAST study. J Trauma Acute Care Surg. 2011;72(1):11–24.CrossRefGoogle Scholar
  143. 143.
    Mackersie RC, Karagianes TG, Hoyt DB, Davis JW. Prospective evaluation of epidural and intravenous administration of fentanyl for pain control and restoration of ventilator function following multiple rib fractures. J Trauma. 1991;31(4):443–51.CrossRefPubMedPubMedCentralGoogle Scholar
  144. 144.
    Knottenbelt JD, James MF, Bloomfield M. Intrapleural bupivacaine analgesia in chest trauma: a randomized double-blind controlled trial. Injury. 1991;22(2):114–6.CrossRefPubMedPubMedCentralGoogle Scholar
  145. 145.
    Lunchette FA, Radafshar SM, Kaiser R, Flynn W, Hassett JM. Prospective evaluation of epidural versus intrapleural catheters for analgesia in chest wall trauma. J Trauma. 1994;36(6):865–70.CrossRefGoogle Scholar
  146. 146.
    Short K, Scheeres D, Mlakar J, et al. Evaluation of intrapleural analgesia in the management of blunt traumatic chest wall pain: a clinical trial. Am Surg. 1996;62:488–93.PubMedPubMedCentralGoogle Scholar
  147. 147.
    el-Baz N, Faber LP, Ivankovich AD. Intrapleural infusion of local anesthetic: a word of caution. Anesthesiology. 1988;68:809–10.CrossRefPubMedPubMedCentralGoogle Scholar
  148. 148.
    Lauder GR. Interpleural analgesia and phrenic nerve palsy. Anaesthesia. 1993;48:315–6.CrossRefPubMedPubMedCentralGoogle Scholar
  149. 149.
    Parkinson SK, Mueller JB, Rich TJ, Little WL. Unilateral Horner’s syndrome associated with interpleural catheter injection of local anesthetic. Anesth Analg. 1989;68:61–2.PubMedPubMedCentralGoogle Scholar
  150. 150.
    Shinohara K, Iwama H, Akama Y, Tase C. Interpleural block for patients with multiple rib fractures: comparison with epidural block. J Emerg Med. 1994;12:441–6.CrossRefPubMedPubMedCentralGoogle Scholar
  151. 151.
    Karmakar MK, Ho AM. Acute pain management of patients with multiple fractured ribs. J Trauma. 2003;54:615–25.CrossRefPubMedPubMedCentralGoogle Scholar
  152. 152.
    Moore KL, Dalley AF. Thorax. In: Kelly PJ, editor. Clincially oriented anatomy. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 1999. p. 59–173.Google Scholar
  153. 153.
    Pedersen VM, Schulze S, Hoier-Madsen K, Halkier E. Air flow meter assessment of the effect of intercostals nerve blockade on respiratory function in rib fractures. Acta Chir Scand. 1983;149:119–20.PubMedPubMedCentralGoogle Scholar
  154. 154.
    Toledo-Pereyra LH, DeMeester TR. Prospective randomized evaluation of intrathoracic nerve block with bupivacaine on postoperative ventilator function. Ann Thor Surg. 1979;27:203–5.CrossRefGoogle Scholar
  155. 155.
    Kaplan JA, Miller ED, Gallagher EG. Postoperative analgesia of thoracotomy patients. Anesth Analg. 1975;54:773–7.PubMedPubMedCentralGoogle Scholar
  156. 156.
    Shanti CM, Carlin AM, Tyburski JG. Incidence of pneumothorax from intercostals nerve blocks for analgesia in rib fractures. J Trauma. 2001;51:536–9.PubMedPubMedCentralGoogle Scholar
  157. 157.
    Baxter AD, Flynn JF, Jennings FO. Continuous intercostal nerve blockade. Br J Anaesth. 1984;56:665–6.CrossRefGoogle Scholar
  158. 158.
    Mowbray A, Wong KK, Murray JM. Intercostal catheterization; an alternative approach to the paravertebral space. Anaesthesia. 1987;42:959–61.CrossRefGoogle Scholar
  159. 159.
    Slinger P. Informal poll taken at thoracic conference. MD Anderson Cancer center, Houston, Nov 2008.Google Scholar
  160. 160.
    Gerner P. Postthoracotomy pain management problems. Anesthesiol Clin. 2008;26:355–67.CrossRefPubMedPubMedCentralGoogle Scholar
  161. 161.
    Conlon NP, Shaw AD, Grichnik KP. Postthoracotomy paravertebral analgesia: will it replace epidural analgesia? Anesthesiol Clin. 2008;26:369–80.CrossRefGoogle Scholar
  162. 162.
    Mohta M, Verma P, Saxena AK, Sethi AK, Tyagi A, Girotra G. Prospective, randomized comparison of continuous thoracic epidural and thoracic paravertebral infusion in patients with unilateral multiple fractured ribs- a pilot study. J Trauma. 2009;66:1096–101.CrossRefPubMedPubMedCentralGoogle Scholar
  163. 163.
    Davies RG, Myles PS, Graham JM. A comparison of the analgesic efficacy and side-effects of paravertebral vs epidural blockade for thoracotomy- a systematic review and meta-analysis of randomized trials. Br J Anaesth. 2006;96:418–26.CrossRefPubMedPubMedCentralGoogle Scholar
  164. 164.
    Karmakar MK, Critchley LAH, Ho AMH, Gin T, Lee TW, Yin APC. Continuous thoracic paravertebral infusion of bupivacaine for pain management in patients with multiple fractured ribs. Chest. 2003;123:424–31.CrossRefPubMedPubMedCentralGoogle Scholar
  165. 165.
    Bulger EM, Edwards T, Klotz P, Jurkovich GJ. Epidural analgesia improves outcome after multiple rib fractures. Surgery. 2004;136:426.CrossRefPubMedPubMedCentralGoogle Scholar
  166. 166.
    Shibata Y, Nishiwaki K. Ultrasound-guided intercostals approach to thoracic paravertebral block. Anesth Analg. 2009;109(3):996–7.CrossRefPubMedPubMedCentralGoogle Scholar
  167. 167.
    Ben-Ari A, Moreno M, Chelly JE, Bigeleisen PE. Ultrasound-guided paravertebral block using an intercostals approach. Anesth Analg. 2009;109(5):1691–4.CrossRefPubMedPubMedCentralGoogle Scholar
  168. 168.
    Hara K, Sakura S, Nomura T, Saito Y. Ultrasound guided thoracic paravertebral block in breast surgery. Anaesthesia. 2009;64(2):223–5.CrossRefPubMedPubMedCentralGoogle Scholar
  169. 169.
    Lönnqvist PA, MacKenzie J, Soni AK, Conacher ID. Paravertebral blockade. Failure rate and complications. Anaesthesia. 1995;50(9):813–5.CrossRefGoogle Scholar
  170. 170.
    Evans PJ, Lloyd JW, Wood GJ. Accidental intrathecal injection of bupivacaine and dextran. Anaesthesia. 1981;36:685–7.CrossRefPubMedPubMedCentralGoogle Scholar
  171. 171.
    Sharrock NE. Postural headache following thoracic somatic paravertebral block. Anesthesiology. 1980;52:360–2.CrossRefPubMedPubMedCentralGoogle Scholar
  172. 172.
    Khalil AE, Abdallah NM, Bashandy GM, Kaddah TA. Ultrasound-guided serratus anterior plane block versus thoracic epidural analgesia for thoracotomy pain. J Cardiothorac Vasc Anesth. 2017;31(1):152–8.CrossRefGoogle Scholar
  173. 173.
    Worthley LI. Thoracic epidural management of chest trauma. Intensive Care Med. 1985;11:312–5.CrossRefGoogle Scholar
  174. 174.
    Ullman DA, Wimpy RE, Fortune JB, Kennedy TM, Greenhouse BB. The treatment of patients with multiple rib fractures using continuous thoracic epidural narcotic infusion. Regional Anesth. 1989;14:43–7.Google Scholar
  175. 175.
    Dittman M, Keller R, Wolff G. A rationale for epidural analgesia in the treatment of multiple rib fractures. Intensive Care Med. 1978;4:193–7.CrossRefGoogle Scholar
  176. 176.
    Ueda K, Ueda W, Manabe M. A comparative study of sequential epidural bolus technique and continuous epidural infusion. Anesthesiology. 2005;103:126–9.CrossRefPubMedPubMedCentralGoogle Scholar
  177. 177.
    Halpern SH, Carvalho B. Patient-controlled epidural analgesia for labor. Anesth Analg. 2009;108:921–8.CrossRefPubMedPubMedCentralGoogle Scholar
  178. 178.
    Joshy GP, Bonnet F, Shah R, Wilkinson RC, Camu F, et al. A systematic review of randomized trials evaluating regional techniques for postthoracotomy analgesia. Anesth Analg. 2008;107:1026–40.CrossRefGoogle Scholar
  179. 179.
    Moon MR, Luchette FA, Gibson SW, et al. Prospective, randomized comparison of epidural versus parenteral opioid analgesia in thoracic trauma. Ann Surg. 1999;229:684–91.CrossRefPubMedPubMedCentralGoogle Scholar
  180. 180.
    Galvagno SM, Smith CE, Varon AJ, et al. Pain management for blunt thoracic trauma: a joint practice management guideline from the Eastern Association for the Surgery of Trauma and Trauma Anesthesiology Society. J Trauma Acute Care Surg. 2016;81(5):936–51.CrossRefPubMedPubMedCentralGoogle Scholar
  181. 181.
    Malekpour M, Hashmi A, Dove J, Torres D, Wild J. Analgesic choice in management of rib fractures: paravertebral block or epidural analgesia? Anesth Analg. 2017;124:1906–11.CrossRefPubMedPubMedCentralGoogle Scholar
  182. 182.
    Unsworth A, Curtis K, Asha SE. Treatments for blunt chest trauma and their impact on patient outcomes and health service delivery. Scand J Trauma Resusc Emerg Med. 2015;23:17.CrossRefPubMedPubMedCentralGoogle Scholar
  183. 183.
    Monaghan SF, Adams CA, Connolly MD, Stephen AH, Lueckel SN, Harrington DT, Cioffi WG, Heffernan DS. A geriatric specific rib fracture protocol significantly improves mortality. Oral presentation as part of the 73rd annual meeting of the American Association for the Surgery of Trauma and Clinical Congress of Acute Care Surgery, Philadelphia, 10–13 Sept 2014.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Stephen V. Panaro
    • 1
  • Tzonghuei Herb Chen
    • 2
  1. 1.Department of AnesthesiaHartford HospitalHartfordUSA
  2. 2.Department of AnesthesiologyWarren Alpert Medical School of Brown University, Rhode Island HospitalProvidenceUSA

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