Up to 20% of patients with penetrating chest injury managed by intercostal drainage alone get complications consisting of:

• Retained haemothorax
• Empyema
• Persistent air leak
• Occult diaphragmatic injury
• Drain malposition / misplacement 

• Trauma doesn’t always respect anatomical boundaries and wounds can often involve both thoracic and abdominal compartments – especially bullets
• Supraclavicular injuries should be managed as a penetrating neck injury and may require a cardiothoracic surgeon, vascular surgeon and ENT 

Stable vs. Unstable (SBP <90mmHg +/- HR >120bpm, not explained by pain, anxiety or hypoxia)

• A FAST scan can assess for pericardial fluid, although cannot rule out a cardiac injury in the presence of a left haemothorax
• Perform an immediate CXR in unstable patients

This is rarely, if ever indicated in the hospital where thoracostomy and chest drain insertion are usually more appropriate.

Principles

• Perform a CXR +/- eFAST
• Patients with no evidence of intrathoracic penetration and no significant chest wall injury can be discharged 

Pneumothorax

• Small pneumothoraces (not visible on initial CXR) can be observed for 24 hours and repeat CXR
• Most small pneumothoraces do not require evacuation, even if intubated
• Pneumothoraces which are visible on the first CXR generally require drainage:
  • 16Fr catheters are acceptable (including seldinger)
  • Patients with any of the following may require image directed drainage:
  • Previous thoracotomy
  • Chronic lung disease
  • Pleural inflammation 

Open chest wounds

• Occlude and place a chest drain
• Theatre for debridement 

Thoracoabdominal injuries

• Up to 20% have diaphragm injuries
• Consider wound location, tract and clinical findings
• Thoracoscopy or laparoscopy for left sided injuries
• Suspected right sided diaphragmatic may not need repair

Haemothoraces

• Small haemothoraces can be observed for 24 hours and repeat CXR
• Use 28-32 Fr chest drain (though 11-16Fr seldinger may be as effective)
• The primary reason for empyema is residual haemothorax after chest drain insertion
• Residual haemothorax seen in the ED on CXR or CT showing >300ml residual are at risk of empyema
•  Often a second chest drain may be recommended
• Consider a VATS procedure for washout and evacuation, ideally within 72 hours when indicated
• Do not use thrombolytics

Indications for thoracotomy / VATs

• Relying on chest tube output may underestimate injury severity
• >1.0L on initial drainage should mandate immediate operative exploration
• >200ml/hr for 4 hours or >1.5L/24 hours should consider operative intervention
• Consideration in the following situations even if <1.5L/24hrs:
  • Large retained haemothorax
  • Transient instability
  •  Clinical features (unexplained acidosis, air leak, diaphragm injury
  • Massive air leak 

Principles

Determine which cavity is the priority to enter first using clinical findings, chest tube output, CXR and FAST. If in any doubt the chest should be entered first to gain proximal control.

• Time to theatre is paramount. Use dedicated code red theatre rather than cardiothoracic theatres
• Crucifix position draped to include proximal thighs and supraclavicular/neck
• Use a single lumen tube (unless skills immediately exist for emergent double lumen placement)
• Perform and ED resuscitative thoracotomy if indicated as per guideline 

Antibiotics

• Administer 1.2g co-amoxicalay for 24 hours in patients requiring intercostal chest drainage for penetrating trauma or surgery, ideally before tube thoracostomy

Damage control

• Consists of packing where possible
• Ligation is generally limited to the left subclavian injury in patients with devastating injuries and coagulopathy
• Tractotomy
• Pneumonectomy and parenchymal resections have a high mortality 

Post-repair/surgery

• IABP/Bypass/ECMO has rarely been used to support the patient with myocardial compromise from coronary artery injury after repair only if haemorrhage controlled
• Delayed closure of the chest may be appropriate in patients who have thoracic compartment syndrome/instability/ongoing diffuse bleeding.
• Manifestations include:
  • Drop in BP and rise in airway pressures when closing the chest