Incidence: 10% of all trauma cases. 25% of trauma deaths in the United Kingdom.

Prognosis: less than 15% of the victims with thoracic injuries require surgery and 80% are managed conservatively with or without a chest drain. Overall mortality of 10%.

Classification: injuries can be described broadly as due to blunt trauma and those due to penetrating injuries (gunshot or stab wounds).

Pathophysiology: blunt injuries may be more difficult to diagnose, often require additional imaging, and are mainly managed with simple interventions like intubation, ventilation and chest-tube insertion. In contrast, penetrating injuries are more likely to require emergency surgery. Patients with penetrating trauma generally deteriorate more rapidly and recover more quickly than patients with blunt injury.

Clinical features: major thoracic trauma can occur without chest wall damage, and the presence of other injuries may delay diagnosis, so high index of suspicion is paramount. The examination and diagnosis should be guided by mechanism and suspicion of injury rather than a direct manifestation.

Initial management and investigation: this follows the basic tenets of resuscitation of all critically injured patients as per ATLS guidelines. The primary goal is to provide oxygen to vital organs. Airway control (A), adequate breathing and ventilation (B), circulation and volume replacement (C) are the top priorities. The patient should be monitored with pulse oximetry and a cardiac monitor (ECG) to ensure adequate ventilation and look for common arrhythmias such as premature ventricular contractions and pulseless electrical activity (PEA). The first-line approach to managing the clinical entities of thoracic trauma is given below. The cardiothoracic team should be involved early on.