EM · Chest trauma
Chest trauma (the immediately and potentially life-threatening injuries)
Also known as Thoracic trauma · Blunt chest injury · Penetrating chest injury · Flail chest
Chest trauma — immediately life-threatening injuries sought in the primary survey (tension pneumothorax, open pneumothorax, massive haemothorax, flail chest with pulmonary contusion, cardiac tamponade, tracheobronchial injury), potentially life-threatening injuries found on secondary survey and imaging (blunt aortic injury, blunt cardiac injury, diaphragmatic rupture, oesophageal injury, pulmonary contusion, simple pneumo/haemothorax), chest-drain and thoracotomy thresholds from sourced reviews, CRASH-2 tranexamic acid timing, PROPPR ratios, EAST emergency-department thoracotomy selection, and TEVAR mortality from the SVS meta-analysis. ACEM-primary, globally tagged.
Checked against its sources on 3 Sept 2026
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Red flags
- A shocked trauma patient with a chest injury has an immediately life-threatening thoracic injury until proven otherwise — treat it in the primary survey, not on the CT table
- A tension pneumothorax is decompressed and then drained — do not wait for imaging
- Chest-tube output over 1500 mL at once, or over 200 mL per hour for 3 hours, with refractory shock, is a damage-control thoracotomy pathway (Grade D), not a drain-and-watch plan
- Tranexamic acid helps bleeding trauma patients when given early; after 3 hours it can increase death due to bleeding
- EAST recommends against emergency-department thoracotomy for the pulseless blunt patient with no signs of life
Meet the patient
A 28-year-old unrestrained driver is dragged from a high-speed wreck, agitated and cyanosed, respiratory rate 32, saturations 86 per cent on 15 L, BP 84 over 52, neck veins distended to the jaw, the right hemithorax hyperresonant with absent breath sounds. There is no time for a CT — and there should not be. The clinical picture is a tension pneumothorax: needle decompression, then a chest tube, then the rest of the primary survey.[15]
Traumatic thoracic injuries are a leading cause of morbidity and mortality worldwide, not only from the injury itself but from secondary insults such as infection, acute kidney injury, acute respiratory distress syndrome, and shock. The thorax houses vital structures, and even seemingly trivial trauma may result in catastrophic damage, particularly in children or older patients.[1]
References18ShowHide
- [1]Kaur N, Lewis S, Jenkinson H, et al. Management of major thoracic trauma: a narrative review Anaesthesia, 2026.PMID 42405450
- [2]van Zyl T, Ho AM, Klar G, et al. Analgesia for rib fractures: a narrative review Can J Anaesth, 2024.PMID 38459368
- [3]Rossaint R, Afshari A, Bouillon B, et al. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition Crit Care, 2023.PMID 36859355
- [4]Shakur H, Roberts I, Bautista R, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial Lancet, 2010.PMID 20554319
- [5]Roberts I, Shakur H, Afolabi A, et al. The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial Lancet, 2011.PMID 21439633
- [6]Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial JAMA, 2015.PMID 25647203
- [7]Clancy K, Velopulos C, Bilaniuk JW, et al. Screening for blunt cardiac injury: an Eastern Association for the Surgery of Trauma practice management guideline J Trauma Acute Care Surg, 2012.PMID 23114485
- [8]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.PMID 18332794
- [9]Seamon MJ, Shiroff AM, Franco M, et al. Emergency department thoracotomy for penetrating injuries of the heart and great vessels: an appraisal of 283 consecutive cases from two urban trauma centers J Trauma, 2009.PMID 20009674
- [10]DuBose J, Inaba K, Demetriades D, et al. Management of post-traumatic retained hemothorax: a prospective, observational, multicenter AAST study J Trauma Acute Care Surg, 2012.PMID 22310111
- [11]Seamon MJ, Haut ER, Van Arendonk K, et al. An evidence-based approach to patient selection for emergency department thoracotomy: a practice management guideline from the Eastern Association for the Surgery of Trauma J Trauma Acute Care Surg, 2015.PMID 26091330
- [12]Link MS Mechanically induced sudden death in chest wall impact (commotio cordis) Prog Biophys Mol Biol, 2003.PMID 12732277
- [13]Maron BJ, Haas TS, Ahluwalia A, Garberich RF, Estes NA 3rd, Link MS Increasing survival rate from commotio cordis Heart Rhythm, 2013.PMID 23107651
- [14]Lee WA, Matsumura JS, Mitchell RS, et al. Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the Society for Vascular Surgery J Vasc Surg, 2011.PMID 20974523
- [15]de Lesquen H, Avaro JP, Gust L, et al. Surgical management for the first 48 h following blunt chest trauma: state of the art (excluding vascular injuries) Interact Cardiovasc Thorac Surg, 2015.PMID 25476459
- [16]Schaefer L, Stein E, Schwarz A, et al. Needle Thoracostomy: Implications of Chest Wall Thickness for Anatomical Location and Needle Length Ann Emerg Med, 2026.PMID 42383960
- [17]Ruthford MR, Shah A, Wolf BJ, et al. Ultrasound Investigation of the Fifth Intercostal Space Landmark for Chest Tube Thoracostomy Site Selection in Pediatric Patients Pediatr Emerg Care, 2024.PMID 38713844
- [18]Gonzalez-Urquijo M, Laor B, Lioupis C, et al. Long-Term Survival following TEVAR for Blunt Thoracic Aortic Injury Ann Vasc Surg, 2026.PMID 41895585