During emergency care, a decision may need to be made as to whether intubation (insertion of a tube (hollow probe) into the trachea/trachea) or a chest drain (drainage system used to drain fluids and/or air from the chest (thorax)) is necessary.
Indications for intubation
- Respiratory insufficiency (respiratory failure; failure of external (mechanical) breathing).
- Unstable thorax
- Severe chest trauma
- Polytrauma (multiple injury)
- GCS (Glasgow Coma Scale/assessment scheme for disorders of consciousness and brain function after traumatic brain injury) < 9 (see “Physical examination” below).
Indications for chest drainage
- Pneumothorax (collapse of the lung caused by an accumulation of air between the visceral pleura (lung pleura) and the parietal pleura (chest pleura)), tension pneumothorax, hemato-pneumothorax (pneumothorax and hematothorax occur in combination)
- Rib serial fracture (at least three adjacent ribs are affected).
- Skin emphysema (air/gas accumulation in the skin).
- Unclear drop in blood pressure
- High ventilation pressures
- Air transport
Approximately one-fifth of patients with chest trauma require chest tube placement. In combination with analgesia (pain therapy) and respiratory therapy, the patient is usually adequately cared for if there are no serious associated injuries.
If a hematothorax is present, the placement of a large-lumen chest tube via minithoracotomy is usually required.
In contrast to blunt trauma, the indication for thoracotomy is much more frequent in penetrating thoracic trauma.
Depending on the injury pattern and clinical symptoms, further thoracic surgery may be required.
Indications
- Pericardial tamponade (cardiac tamponade; e.g., fluid collection in the pericardium).
- Open chest trauma – with persistent (continuing) injury to the heart, vessels, tracheobronchial system, or esophagus (food pipe)
- Esophageal rupture (esophageal tear).
- Blunt thoracic trauma with persistent bleeding in vascular injuries.
- Tracheobronchial ruptures
- Diaphragmatic rupture (rupture of the diaphragm)
At the beginning of the required surgery, a thoracotomy (surgical opening of the thorax) is performed. It is indicated for initial blood loss of > 1.5 liters after chest drainage or if blood loss persists and is > 250 ml/hour over a period of more than four hours.For procedures on the lungs, the patient must first be positioned laterally. Access is via rib resection (surgical removal of a rib) or via an incision of an intercostal space, which means the incision is made in the space between two adjacent ribs (antero-lateral/anterior-lateral or postero-lateral/ posterior-lateral).
