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  1. Frequent causes of immediate death must be ruled out during the primary survey. These include (1) critical airway obstruction, (2) tension pneumothorax, (3) open pneumothorax, (4) massive hemothorax, and (5) cardiac tamponade.

  2. Adequate management of rib fracture pain using multimodal analgesia is critical in preventing further morbidity and mortality.

  3. Delayed repair of aortic transection can be associated with improved mortality, and endovascular stent grafting may become the technique of choice for definitive treatment of BTAI.

This 22-year-old male was the unrestrained passenger of a pickup truck who suffered a head-on collision at high speed. The patient was ejected and suffered severe facial and chest trauma. He was found conscious upon arrival of the emergency medial team but soon deteriorated, requiring tracheal intubation at the scene.

He has multiple facial and chest contusions, is wearing a Philadelphia collar and is positioned on a trauma board. A CXR in the ED showed opacification of the entire left hemithorax. A chest tube was placed which was followed by brisk 2 liter blood loss. He is moved to the OR for emergency thoracotomy.

Trauma is the most common cause of death in the United States for persons between the age of 1 and 44 years, and thoracic trauma accounts for 25% to 50% of all trauma-related mortality.1,2 Patients with thoracic trauma may be managed conservatively in many cases, but the 10% that require urgent or emergent thoracotomy can present tremendous challenges to the anesthesiologists and intensivists involved in their care.2 In particular, members of the trauma care team must simultaneously manage profound hemodynamic instability from massive hemorrhagic or obstructive shock, significant metabolic and acid/base abnormalities, and complex intra- and extrathoracic airway and pulmonary pathology. The complexity and severity of these injuries mandate that the trauma anesthesiologist possess expertise in massive resuscitation, invasive monitoring and line placement, and advanced airway management techniques and equipment. Airway management is further complicated by concerns for associated cervical spine injury and by the fact that the trauma patient is considered to have a full stomach, necessitating a rapid sequence induction and intubation if not already intubated. Thoracic injuries can require prolonged stays in the intensive care unit (ICU) with significant morbidity, including the need for prolonged mechanical ventilation and invasive monitoring. The anesthesiologist may also play a significant role as a pain management consultant and as such must be familiar with a variety of analgesic strategies.

The mechanism of chest injury has important implications for the likelihood of specific organ injury, type of injury present, and its management. Blunt injury can be associated with significant injury to the heart, lungs, great vessels, and esophagus and involves three major mechanisms: compression between osseous structures, direct energy transfer from the impact, and deceleration.3 Compression injury can occur whenever the heart, aorta, or innominate artery is trapped and crushed between the sternum and the thoracic spine as seen when the steering ...

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