Thoracic & Cardiac Trauma

Tension Pneumothorax & Open Pneumothorax Relief (<C>AB): In any hypotensive thoracic trauma patient with absent unilateral breath sounds, severe hypoxia, or PEA arrest, perform immediate Finger Thoracostomy (or 14G, 8 cm angiocatheter needle decompression) at the 4th or 5th Intercostal Space (ICS) slightly anterior to the Mid-Axillary Line (MAL) [1]. For an open “sucking” chest wound (≥ ⅔ tracheal diameter), apply a vented 3-sided occlusive dressing before placing a separate chest tube [1].

Evacuates supra-atmospheric intrapleural pressure (+P(pleural)), immediately uncrimping the superior/inferior vena cava junction and restoring right ventricular venous return (Q(VR) = [MSP − RAP] / R(v)) [1]; converts an open chest wall defect into a one-way flutter valve.

Subxiphoid / Parasternal eFAST for Cardiac Tamponade (C): Perform immediate cardiac POCUS on all penetrating injuries within the “Cardiac Box” (clavicles/sternal notch superiorly, xiphoid inferiorly, mid-clavicular/nipple lines laterally). If pericardial effusion with RV diastolic collapse + refractory hypotension is present, infuse 500 mL whole blood/pRBC to maximize preload (MSP) and mobilize immediately for Operating Room Sternotomy/Thoracotomy (or perform ultrasound-guided pericardiocentesis ONLY as a 3-minute bridge if surgical delay exists) [1,2]. Delay RSI until the chest is prepped and draped!

Acute accumulation of 60–100 mL of blood in the fibrous, non-compliant pericardium equalizes diastolic pressures (P(pericardial) = RA = RV = PCWP). Positive-pressure ventilation and anesthetic sympatholysis abolish compensatory tachycardia and the preload gradient, causing instant arrest.

Emergency Department Resuscitative Thoracotomy (EDT) (If Witnessed Arrest / Loss of Vitals): Perform immediate Left Anterolateral Thoracotomy (or Clamshell extension) at the 4th or 5th ICS for: (1) Penetrating thoracic/cardiac trauma with < 15 min of CPR and Signs of Life (SOL: pupillary reactivity, spontaneous breathing, palpable carotid pulse, extremity movement, or organized ECG activity), or (2) Blunt trauma with < 10 min of prehospital CPR and SOL [2,3]. Incise pericardium anterior and parallel to the phrenic nerve, control myocardial laceration with digital pressure/stapler/sutures, perform bimanual internal massage, and cross-clamp the descending thoracic aorta [2,3].

Evacuates clotted pericardial tamponade that cannot be aspirated by a needle, controls exsanguinating ventricular/hilar hemorrhage, and doubles coronary and cerebral perfusion pressure by occluding subdiaphragmatic arterial runoff [2,3].

Massive Hemothorax Evacuation & Autotransfusion: Insert a 28–32 Fr chest tube (equally efficacious and significantly less painful than 36–40 Fr tubes) [1,4] at the 4th or 5th ICS anterior to the MAL, directed posteriorly and apically. Connect to an autotransfusion collection chamber. Activate MTP (1:1:1) + TXA 1 g IV over 10 min + Calcium Chloride 1 g IV BEFORE clamping or draining > 1,500 mL [1].

Re-expands the collapsed lung so low-pressure pulmonary parenchyma tamponades venous bleeding, while high-pressure intercostal (P(sys)) or internal mammary arterial bleeding (> 1,500 mL initial or > 200 mL/hr × 2–4 hr) mandates surgical thoracotomy [1].

Blunt Thoracic Aortic Injury (BTAI) Anti-Impulse Control (D/E): In high-speed deceleration trauma with widened mediastinum (> 8 cm) or CTA-confirmed aortic pseudoaneurysm/intimal tear at the ligamentum arteriosum (aortic isthmus), initiate immediate β₁-blockade first with Esmolol 500 mcg/kg IV bolus over 1 min, then 50–200 mcg/kg/min (or Labetalol 20 mg IV) to achieve HR ≤ 60–80 bpm, followed by Nicardipine 5–15 mg/hr (if needed) to achieve SBP 100–120 mmHg (MAP 60–70 mmHg) [5,6].

Reduces aortic wall shear stress (dP/dt(max)) and circumferential wall tension (T = P × r / w), preventing adventitial rupture of a contained Grade II/III aortic transection prior to delayed Endovascular Repair (TEVAR) [5,6].