3. Primary approaches in patients with thoracic trauma

Trauma patients in particular should be followed with simple and systematic interventions. In recent years, trauma patients in emergency clinics have usually been treated in line with the American College of Surgeons' advanced life support (ATLS = Advanced Trauma Life Support) protocol, which is classified into primary and secondary care. Primary care consists of approaches for the identification and emergency treatment of life-threatening problems in patients exposed to sudden trauma. The individual or individuals responsible for primary care play significant roles in any intervention carried out related to the survival of trauma patients. Primary care should follow the following stages, the order of which should never be changed: ensuring airway flow and fixation of the neck vertebra (A), evaluation of the respiratory system (B), circulatory system (C), consciousness (D) and total body evaluation (E), known as "ABCDE" [5, 20].

trauma, the bulla or blebs that may already be present in the lungs may rupture, or tracheal bronchi injury may develop [22, 23]. Traumatic pneumothoraxes are classified into three groups

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Simple pneumothorax frequently develops secondary to rib fractures, but may in rare cases develop following barotrauma. The patient presents with major symptoms of pain and dyspnea, and respiratory sounds are decreased at the side of pneumothorax. Diagnosis is based on the visualization of the pleural line on a chest radiography. The air may be spontaneously resorbed in patients with mild pneumothorax, though it may be sufficient to monitor such cases under nasal oxygen therapy. A tube thoracostomy must be performed in moderate or advanced cases of pneumothorax. Considering that the pneumothorax may alleviate in patients connected to mechanical ventilators, a tube thoracostomy should not be delayed in

Open pneumothorax is defined as the deposition of air between the parietal and visceral pleural membranes. In cases of penetrating thoracic trauma, an open pneumothorax develops due following the infiltration of positive pressure atmospheric air into the pleural space after an injury to the thoracic wall and parietal pleura, which is a life-threatening condition that

Pneumothorax may also develop as a result of injuries to the parietal pleura or small airways, even if there is no penetrating injury. With each inspiration of the patient, air enters into the pleural space through the open region on the thoracic wall, as the defect in the thoracic wall is shorter than the trachea and has a lower resistance. In the event of the defect being larger than 0.75-times the tracheal diameter, air enters through the defect instead of the trachea [25], and pushes the heart and major vessels, and the mediastinum to the opposite side. As the capacity of the thoracic space decreases during expiration, the air moves out, and the heart and other mediastinal structures relocate back. This is called "mediastinal flutter". The patient develops hypoxia, asphyxia, respiratory acidosis and decreased cardiac output. Torsion of the vena cava inferior and superior also occurs. Cardiac output decreases upon the decrease in cardiac

The first intervention for open pneumothorax should be the closure of the terminal end of the open defect on the thoracic wall in such a way to that the entry and exit of air is prevented. Alternatively, the pneumothorax could be totally closed, and the patient could be monitored

Tension pneumothorax develops as a result of injury between the parietal and visceral pleural sheets, or injury to the trachea or bronchi. It may develop spontaneously or be iatrogenic, other

as follows: simple, open and tension pneumothorax, which are detailed below.

4.1. Simple pneumothorax

these patients [6, 7].

4.2. Open pneumothorax

requires emergency intervention [24].

venous return, and the patient may go into cardiac arrest.

following a tube thoracostomy (Figure 1) [22, 26].

4.3. Tension pneumothorax

### 3.1. Initial evaluation of life-threatening thoracic trauma

Patients with thoracic traumas are evaluated according to the ATLS protocol. There are six potentially morbid conditions that may occur following thoracic trauma: massive hemothorax, tension pneumothorax, open pneumothorax, flail chest, cardiac tamponade, air embolism and respiratory obstruction. Respiratory obstructions may result in the development of stridor, apnea, cyanosis and subcutaneous emphysema. Broken teeth following trauma, secretions, the development of hematoma due to cervical bleeding, and injuries to the larynx or trachea may result in obstructions of the airways, and these generally represent an indication for emergency intubation [21].

### 3.2. Secondary evaluation of life-threatening thoracic trauma

Secondary care, on the other hand, comprises the urgent identification of potentially lifethreatening conditions and their treatment. Even hemodynamically stable trauma patients should undergo a detailed total body evaluation, and advanced investigations and examinations should be performed by relevant specialists. Detailed investigations are crucial at this stage, as it is possible that some traumas may be overlooked during primary care. It is also important to obtain a detailed anamnesis during secondary care. In the following stage, all body parts of the trauma patients should be evaluated with a physical examination, ultrasonography and/or radiological investigations (such as direct radiographs of the lungs, vertebra, pelvis, extremities, computerized tomography and MRI, if needed), as required [4, 20].
