4.1. Simple pneumothorax

3. Primary approaches in patients with thoracic trauma

3.1. Initial evaluation of life-threatening thoracic trauma

3.2. Secondary evaluation of life-threatening thoracic trauma

"ABCDE" [5, 20].

98 Trauma Surgery

emergency intubation [21].

4. Traumatic pneumothorax

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

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

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].

Traumatic pneumothorax develops when air from the atmosphere or lung parenchyma infiltrates the pleural space following blunt or penetrating trauma. The most commonly encountered etiologic cause is injury of the pleura or the lungs due to rib fractures. In cases of blunt thoracic 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 these patients [6, 7].

### 4.2. Open pneumothorax

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 requires emergency intervention [24].

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

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

### 4.3. Tension pneumothorax

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

5. Traumatic hemothorax

Hemothorax is the deposition of blood between the pleural membranes, and is most frequently caused by trauma. Traumatic hemothorax may originate from the thoracic wall, lungs, blood vessels, mediastinum or diaphragm. In blunt thoracic injuries, hemothorax frequently develops as a result of the bleeding of the pleura or the lung parenchyma, secondary to rib fractures [23]. While patients may remain asymptomatic, they may also present with hypovolemia or even shock, depending on the amount of bleeding. The development of hemothorax in structures with high blood flow, such as the heart, aorta, pulmonary artery,

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Hemothorax also has negative effects on the hemodynamics and respiratory system. Bleeding limits the expansion of the lung at the concerned region, and the mediastinum may shift to the opposite side if the bleeding continues. In an adult, the thorax may unilaterally be infiltrated by up to 6 L of blood. While bleeding of up to 500–750 mL can be tolerated, bleeding of 750– 1500 mL can result in the development of tachycardia and hypotension, and signs of shock start to be seen in the presence of bleeding above 1500 mL (6). Diagnosis is made based on a direct lung radiography and thoracentesis, although thoracic CT is more specific for the diagnosis of hemothorax. Recently, in emergency clinics, bedside USI has also frequently been

A diagnosis of hemothorax can also be made when the hematocrit level in the sample obtained from the pleural space by thoracentesis is more than 50% of the hematocrit level measured in a spontaneously obtained blood sample. In the presence of penetrating traumas, hemothorax is most frequently caused by intercostal artery injuries, which, along with internal mammarian artery injuries, are the most common injuries causing persistent bleeding, and therefore require thoracotomies. For patients who are taken for emergency thoracotomies due to hemorrhagic shock, even applying finger pressure to the bleeding artery can rapidly improve the patient's

Treatment approaches to traumatic hemothorax vary, depending on whether the injury is blunt or penetrating, and on the amount of bleeding. In such cases, the first procedure to be performed should be a tube thoracostomy, as this can serve as an important guide for monitoring the amount of hemothorax and for the prevention of intrathoracic hematoma deposition. Vascular access should be established and appropriate fluid and blood product replacements, such as erythrocyte infusion, should be performed as necessary. The drainage of 1500 mL or more blood following a tube thoracostomy is considered as a massive hemothorax and represents an indication for a thoracotomy. Emergency thoracotomy indica-

Major complications of traumatic hemothorax include thrombus/hematoma in the pleural space, pleural infection, pleural effusion and chylothorax. Clotting blood should be replaced within 1 week following the trauma, or else the hemothorax starts to be organized and the risk

and vena cava inferior and superior, may very quickly become mortal [29, 30].

used for the diagnosis of hemothorax [6, 26, 29, 31].

tions in hemothorax: (Table 1) [23, 26, 31].

of infection increases (Figure 2) [7, 22].

vital signs [32].

Figure 1. PA chest radiography of a case operated on with a right tube thoracostomy due to a developed traumatic right pneumothorax.

than being cause by trauma and is frequently encountered in closed pneumothorax. In tension pneumothorax, there is one-way air entry into the pleural space, and the increased air pressure within the pleural space puts pressure on the lung and pushes the mediastinum to the opposite side, which ultimately applies pressure on the other lung. Pushing the mediastinum along with the heart and other vascular structures towards the opposite thoracic space is called "mediastinal shift".

Increased mediastinal shift impairs cardiac venous filling and presents a life-threatening condition, with the patient developing dyspnea, tachypnea, hypoxia, tachycardia, hypotension and agitation. Radiological imaging shows increased air pressure in the pleural space, the total collapse of the lung on the affected side, the widening of the costal intervals, the detrusion of the diaphragm and the translocation of the mediastinal structures to the opposite side. In the absence of an emergency diagnosis and tube thoracostomy, the patient may experience a dramatic course, including hypoxemia, metabolic acidosis, decreased cardiac output, cardiac arrest or even death.

As an emergency intervention, to empty the air in the pleural space, a thoracentesis can be performed at the point of interception between the midclavicular line and the 2nd intercostal space to empty the air from the intrapleural space, thus reducing the pressure on the lungs and vital organs. After this, a tube thoracotomy should be performed as soon as possible. Of all cases of tension pneumothorax resulting from penetrating thoracic traumas, 75% can be treated with a tube thoracostomy [27, 28].
