1. Introduction

Traumas are one of the main causes of mortality and morbidity worldwide, particularly among young people, and is the leading cause of death in those below 45 years of age and the fourth leading cause of death in all age groups combined [1]. Based on 2012 data from the World Health Organization (WHO), traffic accidents are the 9th leading cause of death worldwide, with more than 1.2 million people dying from traffic accidents every year [2]. Trauma-related

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and eproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

death occurs most frequently in the initial hours following the trauma, and is often associated with bleeding. It is, therefore, of vital importance that patients with general body trauma are urgently, accurately and reliably evaluated in emergency units and the source of bleeding identified [3].

with blunt thoracic trauma, can lead to confusion among healthcare professionals, and so radiological imaging may become necessary [4–6]. In this respect, it is important to retain devices such as ultrasound and X-ray, electrocardiogram (ECG) and echocardiography (ECHO) for the monitoring of trauma patients in emergency clinics. Previous studies have shown that bedside ultrasonography provides more specific and reliable data than physical examinations in assessments of pleural fluid and pneumothorax at the time of initial evalua-

Emergency and Current Approaches to Thoracic Traumas

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When compared with blunt thoracic traumas, penetrating thoracic traumas are less common. Gunshot injuries account for 5% of all thoracic traumas, while sharp object injuries account for almost 37% of cases [14, 15]. Penetrating traumas may occur in isolated regions that requires sudden and mechanical power, at the trauma site, the object may cause tension and contusion in the body, while very severe traumas, on the other hand, may result in organ rupture.

Currently, the probability of survival after a penetrating trauma will be higher when the transfer from the scene of the accident to hospital is quick, and as a result of improvements in the comfort of patient care. In conclusion, the urgent assessment of trauma patients and timely emergency interventions could be life-saving. Moreover, the type of sharp object involved and the time of trauma are crucial in penetrating thoracic injuries. A prospective study has shown that a thoracotomy may be required in 14% of stabbings and 15–20% of gunshot injuries [16]. Not every patient requires a thoracotomy, and so thoracotomy decisions should be based on

The present study aims to describe in detail the steps to be followed from the first presentation until medical intervention for the effective management of patients being referred with any thoracic trauma, and to discuss the current concepts related to the various types of thoracic

From Ancient Greece up to the modern era, most records of thoracic traumas are related to deadly penetrating thoracic injuries. The Edwin Smith Papyrus (3000BC) from the Egyptian era provided information on three patients with penetrating thoracic traumas, two of whom were treated conservatively, while an esophagus suture was used on a cervical esophageal injury in the other [17]. In the thirteenth century, Theodoric defined two forms of rib fracture, based on whether the end of the fracture was turned inward or outward. Ribs that were turned outward were reduced and connected to each other after the application of local medication. In 1767, Larrey spoke about the importance of occlusive dressing and tube drainage in patients with an open hemothorax, although the drainage system used in 1867 by Hillier has been reported to be the most similar to the one being used today [18]. World War II was a turning point in the history of trauma, with the importance of immediately closing the defect in the chest wall following a penetrating thoracic trauma being noted by everyone in the war [19].

tion when a patient presents to the emergency unit with thoracic trauma [10–13].

clinical and radiological evaluations.

traumas.

2. History

Among all forms of trauma, thoracic traumas are the leading cause of mortality after cranial and vertebral traumas. In Turkey, thoracic traumas account for almost 10–15% of all trauma cases seen in emergency units, and approximately 70% of all of these are blunt traumas. The leading cause of blunt thoracic traumas is traffic accidents, while other causes include assault and falls from height, among others. Of all blunt thoracic traumas, almost 15% occur as isolated thoracic traumas, while the rest involve multi-organ traumas, which, in the line of frequency, are traumas of the extremities, head, abdomen, pelvis and vertebra. The rate of mortality is about 2–5% in all thoracic traumas, while this rate may increase to 35% if accompanied by multi-system injuries [4–7].

The outcome of a trauma is determined by the cause and severity of the trauma, as well as the physical status of the exposed individual. Hemodynamics and respiratory parameters gain importance in the presence of thoracic traumas, and possible outcomes may include bleeding, pneumothorax, contusions, heart failure and intrathoracic pressure changes, and such functional abnormalities as hypoxia and hypotension, which may occur due to mediastinal dislocations [4, 8]. The consequences of blunt thoracic traumas may range from simple rib fractures to more severe conditions, such as multiple displaced rib fractures, causing flail chest, tracheal bronchial ruptures and cardiovascular ruptures. The most frequent site affected by thoracic trauma is the thoracic wall, followed in order of frequency by the pleural membranes and lung parenchyma [9].

The most significant cause of mortality, on the other hand, is cardiac and major vessel injuries. Emergency resuscitation, preferential diagnosis, basic interventions (such as thoracentesis or catheter/tube thoracotomy) and effective treatment are the necessary interventions for patients presenting with a trauma. The first assessment should involve checking the circulation and airways. Sternotomies or and thoracotomies are required in 10% of all blunt injuries, while emergency thoracotomies are required in 1–2% of cases [8]. Around one-third of all deaths occur at the time of trauma, while the remaining two-thirds occur after presentation to the emergency unit and medical interventions. The period from the trauma until the first hospital admission is considered as the "golden time" [5], as mortalities could be decreased by almost 30% with the timely transfer of patients from the trauma site, the effective implemented emergency resuscitation, and the emergency diagnosis and interventions at the hospital. Due to the high probability of mortality and morbidity, patients with thoracic traumas should be routinely monitored by Chest Surgeons, Emergency Medicine Specialists, specialists from the other relevant fields, nurses and other healthcare providers, all of whom play significant roles in both the diagnosis and treatment of such patients [2].

The presence of other injuries, such as large bone fractures, head traumas, intoxication, brain hypoxia or shock findings, as identified during the physical examination of patients presenting with blunt thoracic trauma, can lead to confusion among healthcare professionals, and so radiological imaging may become necessary [4–6]. In this respect, it is important to retain devices such as ultrasound and X-ray, electrocardiogram (ECG) and echocardiography (ECHO) for the monitoring of trauma patients in emergency clinics. Previous studies have shown that bedside ultrasonography provides more specific and reliable data than physical examinations in assessments of pleural fluid and pneumothorax at the time of initial evaluation when a patient presents to the emergency unit with thoracic trauma [10–13].

When compared with blunt thoracic traumas, penetrating thoracic traumas are less common. Gunshot injuries account for 5% of all thoracic traumas, while sharp object injuries account for almost 37% of cases [14, 15]. Penetrating traumas may occur in isolated regions that requires sudden and mechanical power, at the trauma site, the object may cause tension and contusion in the body, while very severe traumas, on the other hand, may result in organ rupture.

Currently, the probability of survival after a penetrating trauma will be higher when the transfer from the scene of the accident to hospital is quick, and as a result of improvements in the comfort of patient care. In conclusion, the urgent assessment of trauma patients and timely emergency interventions could be life-saving. Moreover, the type of sharp object involved and the time of trauma are crucial in penetrating thoracic injuries. A prospective study has shown that a thoracotomy may be required in 14% of stabbings and 15–20% of gunshot injuries [16]. Not every patient requires a thoracotomy, and so thoracotomy decisions should be based on clinical and radiological evaluations.

The present study aims to describe in detail the steps to be followed from the first presentation until medical intervention for the effective management of patients being referred with any thoracic trauma, and to discuss the current concepts related to the various types of thoracic traumas.
