Quick Answer

Penetrating chest trauma requires rapid assessment and immediate life-saving interventions. Follow ATLS primary survey with focus on airway, breathing, circulation. Identify six life-threatening injuries: airway obstruction, tension pneumothorax, massive haemothorax, open pneumothorax, flail chest, cardiac tamponade. Resuscitative thoracotomy indicated for patients with signs of life who lose vital signs en route or in ED, or with penetrating cardiac injury with signs of life. Transfer to definitive care (trauma theatre or interfacility transfer) after initial stabilisation.

ACEM Exam Focus

Fellowship Written: Expect SAQs on thoracotomy indications, chest tube management, specific injury patterns (cardiac, pulmonary, diaphragmatic). Viva questions often focus on decision-making for operative vs non-operative management, and interpretation of imaging findings.

Fellowship OSCE: Resuscitation station with haemodynamically unstable patient. Communication scenarios involving bad news delivery or discussing need for emergency thoracotomy with family. Procedure assessment of chest tube insertion.

Primary Viva: Applied anatomy of chest wall, heart, great vessels. Mechanism of cardiac tamponade physiology. Physics of tension pneumothorax and needle decompression.

Key Points

• Penetrating chest injuries account for 10-15% of all trauma deaths in Australasia
• Six immediately life-threatening thoracic injuries must be identified in primary survey
• Cardiac tamponade presents with Beck's triad (hypotension, muffled heart sounds, JVD) - pulsus paradoxus is a late sign
• Massive haemothorax defined as greater than 1500mL initial drainage or more than 200mL/hour for 4 hours
• Resuscitative thoracotomy has survival rate of 8-35% depending on mechanism and presenting signs
• Left anterolateral thoracotomy provides access to heart, left lung, descending aorta, and allows cross-clamping
• Diaphragmatic injuries occur in 1-5% of penetrating thoracoabdominal trauma and are often missed on initial imaging
• Indigenous Australians have 2-3 times higher trauma mortality due to geographic and socioeconomic factors

Epidemiology

Incidence and Mortality

Penetrating chest trauma represents a significant proportion of traumatic injuries in Australia and New Zealand. Data from the Australian and New Zealand Trauma Registry shows:

• Penetrating thoracic trauma: 10-15 cases per 100,000 population annually
• Overall mortality: 25-40% for all penetrating chest injuries
• Cardiac injury mortality: 60-80% despite rapid intervention
• Stabbing vs gunshot: Stabbing has lower mortality (15-25%) compared to gunshot wounds (30-50%)
• Age distribution: Peak incidence in males aged 20-40 years
• Gender distribution: More than 90% of cases involve male patients

Australian Context

NSW Trauma Registry data demonstrates penetrating chest injuries account for 12% of major trauma presentations. Queensland Trauma Registry shows similar patterns with seasonal variations.

Indigenous Health Disparities: Aboriginal and Torres Strait Islander peoples experience disproportionate trauma burden: 2-3 times higher incidence, delayed presentation (median 2-4 hours longer), higher complication rates and mortality, geographic isolation contributes significantly, cultural barriers compound disparities.

Rural and Remote Challenges: Limited access to cardiothoracic surgery, delayed transfer times (4-12 hours), limited blood product availability, reduced access to advanced imaging, fewer experienced trauma team members.

Pathophysiology

Primary Thoracic Injuries

Penetrating chest trauma causes injury through direct tissue disruption, cavitation effects, and secondary blast injuries. Physiological consequences determined by: anatomical structures injured (heart, lungs, great vessels, chest wall, diaphragm), severity of haemorrhage, cardiovascular compromise (tamponade, hypovolaemia, tension), and respiratory compromise (parenchymal injury, pneumothorax, airway disruption).

Cardiac Injury Physiology

Pericardial tamponade develops when blood accumulates in pericardial space. Pericardium has limited compliance - initial 50-100mL causes pressure rise. Rapid accumulation of 150-250mL can cause haemodynamic collapse. Equalisation of pericardial, right atrial, and right ventricular diastolic pressures. Decreased stroke volume and cardiac output despite normal systolic function. Compensatory tachycardia and vasoconstriction maintain BP until decompensation.

Cardiac chamber involvement: Right ventricle most commonly injured (43%), left ventricle (33%), right atrium (16%), left atrium (8%). Ventricular injuries have higher mortality due to thicker musculature.

Pneumothorax and Haemothorax Pathophysiology

Tension pneumothorax occurs when one-way valve mechanism allows air entry but prevents escape. Progressive accumulation causes ipsilateral lung collapse, mediastinal shift compresses contralateral lung, decreased venous return and cardiac output leads to cardiovascular collapse. Can be fatal within minutes.

Massive haemothorax causes hypovolaemic shock from blood loss (up to 40% blood volume), ipsilateral lung collapse, mediastinal shift, and hypoxia from ventilation-perfusion mismatch.

Diaphragmatic Injury

Mechanism of missed diagnosis: Diaphragm moves with respiration - small wounds may not be apparent, omental herniation may seal defect initially, symptomatic presentation often delayed (months to years), left-sided injuries more common (2:1 ratio) due to liver protection on right.

Clinical Approach

Primary Survey (ABCDE)

A - Airway with C-spine Protection

Assess airway patency, anticipate need for definitive airway. Indications for intubation: decreased level of consciousness (GCS less than 8), respiratory failure despite supplemental oxygen, massive haemorrhage requiring operative intervention, anticipated clinical course. Consider cervical spine injury with high-velocity wounds.

B - Breathing and Ventilation

Immediate life threats: Tension pneumothorax (tracheal deviation, absent breath sounds, hyperresonance, hypotension, distended neck veins), open pneumothorax (large chest wall defect), massive haemothorax (dullness, absent breath sounds, hypovolaemic shock), flail chest (paradoxical movement).

Immediate interventions: Needle decompression (second intercostal space, midclavicular line, 14-16 gauge cannula, 5-8cm length), chest tube insertion (fifth intercostal space, anterior axillary line, 32-36 French for haemothorax), occlusive dressing for open pneumothorax (three-sided).

C - Circulation with Haemorrhage Control

Assessment: Pulse rate, blood pressure, capillary refill, JVD, cardiac sounds, peripheral pulses.

Identify: Cardiac tamponade (Beck's triad, pulsus paradoxus greater than 12mmHg), hypovolaemic shock (tachycardia, hypotension, cool peripheries), massive haemothorax (hypovolaemic signs with respiratory compromise).

Immediate interventions: Two large-bore IVs (14-16 gauge), blood product administration (O-negative uncrossmatched initially), massive transfusion protocol activation (ABC score 2 or greater), permissive hypotension (target SBP 80-90mmHg), FAST examination.

D - Disability

Assess Glasgow Coma Scale, pupil size and reactivity, lateralising signs. Consider traumatic brain injury, hypoxic brain injury, or spinal cord injury.

E - Exposure and Environmental Control

Complete secondary survey with log-roll. Cover patient to prevent hypothermia.

Secondary Survey

Complete head-to-toe examination: mark entry and exit wounds, estimate wound track, assess associated injuries, neurological examination.

Investigations

Immediate Bedside Investigations

Focused Assessment with Sonography for Trauma (FAST)

Pericardial view: Subxiphoid window, assess for pericardial effusion. Sensitivity 80-90% for cardiac tamponade. Presence of effusion with haemodynamic instability mandates thoracotomy.

Pericardial effusion classification: Small (less than 10mm), moderate (10-20mm), large (greater than 20mm immediate drainage), tamponade physiology (RA/RV collapse, respiratory variation).

ECG

ECG changes: ST segment changes, arrhythmias, electrical alternans, low voltage. Sensitivity 30-50% but high specificity.

Chest X-ray

Anteroposterior supine film: pneumothorax (deep sulcus sign, pleural line), haemothorax (opacification, mediastinal shift), widened mediastinum, foreign bodies, rib fractures. Supine sensitivity for pneumothorax 50-75%.

Blood Investigations

Arterial blood gas: Lactate greater than 4mmol/L predicts mortality, base deficit greater than -6 indicates shock. Full blood count: Haemoglobin baseline, platelet count. Coagulation: INR, aPTT, fibrinogen less than 1.5g/L requires replacement. Biochemistry: Calcium monitoring less than 1.0mmol/L. Blood products: Type and cross 4 units minimum.

CT Imaging

Indications: Haemodynamically stable patient, wound trajectory assessment, occult injuries (great vessels, esophagus, diaphragm), surgical planning.

CT findings: Lung parenchymal lacerations, pleural collections, chest wall defects, mediastinal haematoma, diaphragmatic injury (segmental defect, herniated viscera), great vessel injury (contrast extravasation). CT angiography: Wounds near great vessels, mediastinal haematoma, pulse deficit.

Management

Initial Resuscitation

Airway and Breathing Management

Definitive airway: Rapid sequence intubation, lung-protective ventilation (tidal volume 6-8mL/kg), PEEP 5-10cmH2O, target PaO2 80-100mmHg, SpO2 94-98%, PaCO2 35-45mmHg.

Chest tube management: Fifth intercostal space, anterior axillary line, 32-36 French for haemothorax, -20cmH2O suction, document drainage, ongoing more than 200mL/hour for 4 hours requires thoracotomy.

Circulation and Haemorrhage Control

Access: Two large-bore IVs, consider intraosseous, central venous access.

Fluid resuscitation: Crystalloids limit to 1L, O-negative blood initially, MTP 1:1:1 ratio, calcium 1g after every 4 units, TXA 1g loading over 10 minutes then 1g over 8 hours (within 3 hours).

Permissive hypotension: Target SBP 80-90mmHg, maintain MAP greater than 65mmHg, reassess with each intervention.

Focused Assessment with Sonography for Trauma (FAST)

Positive pericardial view: Immediate resuscitative thoracotomy if unstable, consider pericardiocentesis if stable. Negative pericardial view: Repeat examinations, consider CT or TOE.

Definitive Management

Indications for Thoracotomy

Emergency Department Thoracotomy (EDT): Penetrating chest trauma with loss of vital signs in field/transport, penetrating cardiac injury with signs of life at scene/arrival, penetrating thoracic trauma with tamponade and instability, severe hypovolaemic shock unresponsive.

Contraindications: Asystole more than 15-20 minutes without interventions, no signs of life at scene with prolonged transport, severe unsurvivable brain injury, DNR status, blunt trauma with asystole (less than 1% survival).

Operating Room Thoracotomy: Greater than 1500mL initial drainage or more than 200mL/hour for 4 hours, ongoing bleeding despite chest tube, suspected great vessel injury, retained haemothorax, diaphragmatic injury, cardiac injury with tamponade stable for transport.

Resuscitative Thoracotomy Technique

Left Anterolateral Thoracotomy: 1) Position (supine, left arm elevated, left side 30 degrees elevated), 2) Incision (curved from left sternocostal to fifth ICS midaxillary, extend to clamshell if bilateral), 3) Entry (fourth/fifth ICS, divide intercostals), 4) Pericardiotomy (longitudinal anterior to phrenic nerve, evacuate clot), 5) Cardiac massage (80-100/min), 6) Cross-clamp descending aorta (if no BP despite massage), 7) Repair injuries (pledgeted 3-0 or 4-0 polypropylene), 8) Defibrillation (20-50J biphasic internal paddles).

Survival: Penetrating cardiac with signs of life (20-35%), thoracic without cardiac (15-25%), blunt (less than 5%).

Complications: Blood-borne pathogen exposure, infection, phrenic nerve injury, recurrent tamponade, thoracotomy complications.

Chest Tube Management

Indications: Pneumothorax (symptomatic or greater than 20% lung volume), haemothorax (any visible), haemopneumothorax, post-thoracotomy, tension (after needle decompression).

Technique: Position supine with arm abducted, fifth ICS anterior axillary line, local anaesthetic (1% lignocaine with adrenaline), 2-3cm incision parallel to rib, blunt dissection through intercostals, insert tube (posteriorly/superiorly for pneumothorax, posteriorly/inferiorly for haemothorax), connect to -20cmH2O suction, secure with suture, confirm with CXR.

Removal criteria: Lung fully expanded, no air leak 24 hours, drainage less than 100-150mL/24h, patient clinically improved, residual less than 300mL.

Complications: Incorrect placement, bleeding, infection, re-expansion pulmonary oedema, persistent air leak.

Diaphragmatic Injury Management

Diagnosis: High index of suspicion, CT with sagittal/coronal reconstructions, diagnostic laparoscopy/thoracoscopy if CT equivocal. Left diaphragm injuries more common, more difficult to diagnose.

Surgical repair: Laparotomy for acute abdominal injuries (full abdominal exploration), thoracotomy for isolated thoracic or chronic repairs, primary repair with non-absorbable suture (0 or 1 polypropylene), prosthetic patch for large defects or delayed repair with tissue loss.

Missed injuries: May present months to years with herniation, repair via thoracic approach.

Specific Injury Patterns

Cardiac Injuries

Anatomical distribution: Right ventricle (43%, anterior), left ventricle (33%, thick wall higher mortality), right atrium (16%, thin wall survivable), left atrium (8%, posterior often fatal).

Clinical presentation: Cardiac tamponade (Beck's triad, pulsus paradoxus), haemorrhagic shock (external wound, open pericardium), electromechanical dissociation, arrhythmias.

Management: Resuscitative thoracotomy for unstable, pericardial window/pericardiocentesis for stable, pledgeted sutures (3-0 or 4-0 polypropylene), bypass for complex, ICU monitoring.

Pulmonary Injuries

Types: Lung laceration (parenchymal tear with haemorrhage/air leak), pulmonary contusion (haemorrhage without laceration), bronchial injury (mainstem disruption rare high mortality), pulmonary artery injury (major vessel haemorrhage).

Clinical presentation: Haemoptysis, persistent air leak, respiratory distress, haemodynamic instability (major vessel).

Management: Chest tube for most, thoracotomy for massive air leak/ongoing bleeding/major vessel, lung resection (wedge, segmentectomy, lobectomy), pulmonary tractotomy for through-and-through, conservative for minor.

Vascular Injuries

Great vessels: Aortic (ascending, arch, descending), pulmonary artery (main/lobar), SVC/IVC, subclavian vessels.

Clinical presentation: Widened mediastinum, massive haemothorax, haemodynamic instability disproportionate, upper extremity pulse deficits, pseudocoarctation (differential BP between arms).

Management: CT angiography for stable patients, immediate thoracotomy for unstable, vascular repair (primary or graft), endovascular for selected (descending aorta), shunt for complex.

Chest Wall and Rib Injuries

Rib fractures: Isolated (pain management, incentive spirometry), flail segment (ventilation may be required), first/second rib fractures (high-energy assess great vessels), multiple (higher morbidity, pneumonia risk).

Management: Analgesia (multimodal - paracetamol, opioids, NSAIDs), regional (paravertebral block, epidural for severe), surgical stabilisation (selected flail), pulmonary toilet (incentive spirometry, chest physio).

Complications

Early Complications

Haemorrhagic: Ongoing bleeding (thoracotomy or embolisation), coagulopathy (dilutional, consumptive, hypothermic), rebleeding after control (reoperation).

Respiratory: ARDS (lung injury, transfusion-related), pneumonia (aspiration, prolonged ventilation), atelectasis, persistent air leak.

Cardiac: Recurrent tamponade, myocardial infarction, arrhythmias, pericarditis.

Late Complications

Infectious: Empyema, wound infection, mediastinitis, osteomyelitis.

Structural: Diaphragmatic hernia, thoracic aneurysm, bronchopleural fistula, chest wall deformity.

Chronic sequelae: Chronic pain, dyspnoea, reduced exercise tolerance, psychological (PTSD, anxiety, depression).

Special Considerations

Paediatric Penetrating Chest Trauma

Anatomical differences: More compliant chest wall (greater energy transmission), relative mediastinal mobility (less tension presentation), smaller blood volume (more rapid decompensation), higher cardiac mobility.

Management: Lower thresholds for intervention, age-appropriate equipment, consider non-operative more aggressively, higher missed injury risk (communication limitations).

Geriatric Penetrating Chest Trauma

Physiological differences: Reduced physiological reserve, comorbidities, medications (anticoagulants, antiplatelets), reduced chest wall compliance.

Management: Lower threshold for aggressive, higher complication risk, careful fluid/blood titration, consider goals of care early.

Pregnancy

Physiological changes: Increased blood volume (40-50%), displaced mediastinum, reduced FRC, IVC compression.

Management: Left lateral tilt (15-30 degrees), foetal monitoring after 20 weeks, consider radiation risks, OBGYN consultation early, emergency caesarean section for maternal arrest after 20 weeks.

Indigenous Health

Aboriginal and Torres Strait Islander Considerations: Cultural safety (Aboriginal health workers, culturally appropriate communication), family involvement (decision-making, presence), language barriers (interpreter services), trust building, community support.

Māori Considerations: Whānau involvement (extended family integral), Tikanga Māori (protocols around death/dying), Kai Māori (traditional food), Wairua (spiritual wellbeing).

Outcome disparities: Indigenous patients 2-3 times higher mortality. Contributing: delayed presentation, geographic isolation, comorbidities, access barriers. Need culturally safe pathways, community-based prevention.

Remote and Rural Considerations

Challenges: Limited access to cardiothoracic surgery, delayed transfer, limited blood products, fewer experienced team members, limited advanced imaging.

Management adaptations: Early consultation with trauma centre, pre-hospital aeromedical activation, frozen plasma/whole blood, telemedicine support, standardised protocols.

Royal Flying Doctor Service (RFDS): 24/7 aeromedical retrieval, blood products available, critical care teams, coordination essential.

State-specific: NSW (statewide trauma system), QLD (retrieval through RSQ), WA (RFDS primary), SA (MedSTAR), NT (high Indigenous), VIC (integrated pre-hospital/hospital), TAS (interstate transfer), ACT (coordinated with NSW), NZ (regional networks, aeromedical retrieval).

Disposition

Admission Criteria

High dependency/ICU: Haemodynamic instability despite resuscitation, respiratory failure requiring ventilation, post-thoracotomy, cardiac injury (even if stable), massive haemothorax/ongoing bleeding, severe pulmonary contusion.

Ward: Stable after chest tube, small haemothorax (less than 500mL) resolving, isolated rib fractures with analgesia, minor pneumothorax with lung re-expansion.

Operative: Immediate theatre (ongoing bleeding, cardiac tamponade, great vessel), urgent within 24 hours (retained haemothorax, diaphragmatic injury, persistent air leak).

Safe Discharge

Criteria: Normal CXR after chest tube removal, haemodynamically stable with normal vitals 4-6 hours, adequate analgesia, reliable support person, no concerns for missed injuries, discharge instructions with safety netting.

Follow-up: Surgical clinic 1-2 weeks, CXR 2-4 weeks, physiotherapy, repeat imaging if symptoms persist.

Transfer Criteria

Interfacility transfer: Haemodynamic instability, need for thoracotomy/cardiac surgery, great vessel injury suspected/confirmed, cardiac injury suspected/confirmed, severe pulmonary injury, diaphragmatic injury, complex multiple injuries.

Transfer preparation: Stabilise before transfer (airway secured, chest tube inserted, resuscitation initiated), accompanying medical team, ongoing monitoring, communication with receiving team, all imaging sent.

Pitfalls and Pearls

Common Pitfalls

Missed injuries: Diaphragmatic (high suspicion for thoracoabdominal wounds), cardiac (repeat FAST/ECG), great vessel (consider trajectory, widened mediastinum, pulse deficits), oesophageal (posterior mediastinum).

Inadequate resuscitation: Under-transfusion (adhere to MTP), inadequate analgesia (multimodal, regional), delayed thoracotomy (don't delay for imaging in unstable), missed permissive hypotension (avoid over-resuscitation).

Procedural: Incorrect chest tube (confirm with CXR), missed tension pneumothorax (decompress before imaging), inadequate cardiac exposure (extend to clamshell), vascular injury during thoracotomy (careful dissection, proximal control).

Clinical Pearls

Assessment: "All that bleeds is not in chest"

• consider abdominal sources. Stab wounds may have surprising trajectory. Repeated FAST valuable. Tracheal deviation late sign of tension pneumothorax - intervene earlier.

Management: "If in doubt, cut it out"

• thoracotomy for unstable. Chest tube size matters (32-36F for haemothorax). Left anterolateral provides access to most critical structures. Cross-clamp descending aorta if no BP despite cardiac massage.

Communication: Involve family early but don't delay interventions. Clear closed-loop communication. Document discussions. Consider cultural needs.

Viva Practice

Viva 1: Indications for Resuscitative Thoracotomy

Stem: A 28-year-old male presents after stab wound to left chest. Had pulse at scene but lost vital signs during transport. On arrival, pulseless with CPR in progress. Transport time 10 minutes.

Q1: What are your immediate priorities and actions?

A1: 1) Continue CPR during handover. 2) Call for help - activate trauma team, notify theatre, prepare for thoracotomy. 3) Establish access (two large-bore IVs or IO). 4) Simultaneous: needle decompression if tension pneumothorax suspected, administer O-negative blood immediately, prepare for left anterolateral thoracotomy, prepare defibrillator for internal cardioversion.

This patient meets criteria for EDT: penetrating chest trauma, had signs of life at scene, lost vital signs during transport.

Q2: What is survival rate for EDT in this scenario, and what factors influence survival?

A2: Survival rates 20-35%. Positive: penetrating mechanism, cardiac injury, signs of life at scene, short transport less than 15 minutes, isolated thoracic, rapid thoracotomy within 10 minutes, pericardial tamponade. Negative: asystole more than 15-20 minutes, blunt trauma less than 5%, no signs of life at scene, prolonged transport more than 15-20 minutes, severe brain injury, multiple major injuries.

Q3: Describe the technique for left anterolateral thoracotomy.

A3: 1) Positioning: supine, left arm abducted 90°, left side elevated 30°. 2) Incision: curved from left sternocostal along inframammary crease to fifth ICS midaxillary. 3) Entry: fourth/fifth ICS, divide muscles bluntly. 4) Rib spreader: insert Finochietto retractor gradually. 5) Pericardiotomy: longitudinal anterior to left phrenic nerve, evacuate clot. 6) Cardiac inspection: identify injuries, temporarily occlude with finger. 7) Cardiac repair: pledgeted 3-0 or 4-0 polypropylene for ventricular wounds. 8) Internal cardiac massage: 80-100/min if no output. 9) Aortic cross-clamp: descending aorta above diaphragm if no BP despite massage. 10) Defibrillation: 20-50J biphasic internal paddles. 11) Chest tube: 32-36F before closure. Extend to clamshell if bilateral access required.

Q4: What are the contraindications to EDT, and how would you manage this patient if he were not a candidate?

A4: Absolute: asystole more than 15-20 minutes without interventions, no signs of life at scene with prolonged transport more than 15-20 minutes, DNR, severe unsurvivable brain injury. Relative: blunt trauma with asystole (less than 1% survival), multiple traumatic injuries with nonsurvivable prognosis, prolonged downtime with poor neurological prognosis.

If not candidate: 1) Continue brief resuscitation 5-10 minutes while confirming no signs of life. 2) Confirm prognosis with trauma team. 3) Cease resuscitation after confirming no reversible causes. 4) Document time of death, findings, reasons. 5) Sensitively communicate with family, provide support. 6) Coroner notification (required for all trauma deaths). 7) Preserve forensic evidence (do not remove weapons if present).

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Viva 2: Cardiac Tamponade

Stem: A 34-year-old female presents after being stabbed in left chest. BP 85/60, HR 125, SpO2 94% on 15L O2. Wound in left fourth ICS, midclavicular line. Neck veins distended. Heart sounds muffled.

Q1: What is your differential diagnosis, and what are key features that suggest a specific diagnosis?

A1: Differential: cardiac tamponade, tension pneumothorax, massive haemothorax, simple pneumothorax with hypovolaemia, vagal response.

Key for cardiac tamponade: Beck's triad (hypotension 85/60, muffled heart sounds, JVD), pulsus paradoxus greater than 12mmHg, tachycardia 125, wound location overlying cardiac silhouette. Distinguishing from tension pneumothorax: breath sounds present (decreased) in tamponade vs absent in tension, hyperresonance vs normal/dull, no tracheal deviation in tamponade.

Q2: What investigations would you perform in this patient, and what findings would confirm cardiac tamponade?

A2: FAST pericardial view: anechoic fluid around heart. Size small (less than 10mm), moderate (10-20mm), large (greater than 20mm). Tamponade signs: RA/RV collapse, respiratory variation in mitral inflow. Sensitivity 80-90%. ECG: ST changes, arrhythmias, electrical alternans (specific for large effusion), low voltage. Sensitivity 30-50%. CXR: widened mediastinum, enlarged cardiac silhouette. ABG: oxygenation, lactate (elevated indicates shock), base deficit.

Confirmatory: FAST with effusion and haemodynamic instability, pulsus paradoxus greater than 12mmHg, electrical alternans, echocardiography RA/RV collapse.

Q3: Describe your management approach for this patient.

A3: Simultaneous: call for help (trauma team, theatre, blood bank), establish two large-bore IVs, 15L O2, cardiac monitoring. Fluid: 500mL crystalloid bolus, MTP (O-negative blood), permissive hypotension SBP 80-90, calcium 1g if ionised less than 1.0mmol/L. Definitive: resuscitative thoracotomy indicated given haemodynamic instability with suspected cardiac injury. Prepare for left anterolateral thoracotomy.

Alternative: pericardiocentesis if stabilises (subxiphoid approach, 18G needle, aspirate until blood removed, leave catheter - often unsuccessful with clotted blood). Subxiphoid pericardial window in OR (allows visualisation, diagnostic and therapeutic). Definitive: pledgeted sutures, coronary bypass if needed, pericardial drainage, ICU monitoring.

Q4: What are the potential complications of cardiac injury and its management?

A4: Early: recurrent tamponade (incomplete evacuation, re-exploration), arrhythmias (antiarrhythmics, pacing, defibrillation), myocardial infarction (revascularisation), cardiac failure (inotropes, afterload reduction, surgical repair if required), infection (antibiotics, drainage). Late: pericardial constriction (progressive dyspnoea, JVD, pericardiectomy), ventricular aneurysm (arrhythmias, anticoagulation, repair if symptomatic), valvular dysfunction (repair/replacement), post-cardiac injury syndrome (fever, chest pain, NSAIDs, colchicine, steroids).

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Viva 3: Massive Haemothorax

Stem: A 42-year-old male presents after gunshot wound to right chest. BP 70/45, HR 135, SpO2 88% on 15L O2. Right chest dull to percussion with absent breath sounds. Needle decompression releases no air. Chest tube drains 1600mL blood immediately.

Q1: What is your diagnosis, and what are the definitions of haemothorax severity?

A1: Diagnosis: Massive haemothorax. Definitions: Minimal (less than 300mL, often asymptomatic, observe), Moderate (300-1500mL, dyspnoea/tachycardia, chest tube), Massive (greater than 1500mL initial OR more than 200mL/hour for 4 hours, haemodynamic instability, thoracotomy), Clotted (blood clots, persistent CXR opacification, VATS/thoracotomy evacuation within 7-10 days). Patient meets massive criteria.

Q2: What are the sources of bleeding in massive haemothorax, and what structures are most commonly injured?

A2: High-volume requiring thoracotomy: pulmonary vessels (lobar/segmental branches, through-and-through injuries, high-pressure, most common), systemic vessels (intercostal arteries - posterior branches larger, internal mammary, lateral thoracic, subclavian, systemic pressure), great vessels (aorta ascending/arch/descending, SVC/IVC, usually rapidly fatal). Moderate-volume: lung parenchyma (pulmonary lacerations/contusions, pulmonary pressure, often stops spontaneously), chest wall (soft tissue, low volume). Most commonly: lung parenchyma, intercostal vessels, pulmonary vessels, great vessels (highest mortality).

Q3: What is your immediate management plan for this patient?

A3: Immediate: call for help (trauma team, theatre immediately), airway/breathing (15L O2, prepare for RSI), circulation (two large-bore IVs, MTP activation, O-negative blood, permissive hypotension SBP 80-90, calcium 1g after 4 units, TXA 1g loading), FAST (assess pericardial effusion), ensure chest tube functioning, autotransfusion if available.

Prepare for immediate thoracotomy: indications met (greater than 1500mL), likely ongoing bleeding, gunshot higher energy. Transfer to OR: continue resuscitation, blood products ongoing, theatre prepared, anaesthesia standby.

Definitive: right posterolateral thoracotomy, identify and control bleeding source (pulmonary vessel ligation/repair, intercostal ligation, lung tractotomy/wedge resection/lobectomy), thorough evacuation, chest tube post-repair, ICU.

Q4: What are the indications for emergency department thoracotomy versus operating room thoracotomy in this scenario?

A4: EDT: loss of vital signs in field/transport, severe hypotension unresponsive to resuscitation (SBP persistently less than 60-70 despite blood), cardiac arrest imminent with no time for safe transfer, cardiac injury suspected with tamponade physiology.

ORT: initial drainage greater than 1500mL (meets criteria), ongoing drainage more than 200mL/hour for 4 hours, haemodynamic instability but with pulses present, suspected major vascular injury, patient stable enough for safe transfer.

This patient meets ORT criteria: greater than 1500mL, haemodynamically unstable but with pulses present. Should be rapidly transferred to OR. Decision factors: transport time if OR adjacent less than 2-3 minutes ORT preferred, patient status if deteriorates during transfer perform EDT in ED, resources if limited OR availability or prolonged transport consider EDT, surgeon availability if trauma surgeon immediately available ORT preferred.

Key principle: Rapid thoracotomy and source control whether EDT or ORT.

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Viva 4: Diaphragmatic Injury

Stem: A 29-year-old male presents 3 hours after being stabbed in left lower chest. Wound in left sixth ICS, midaxillary line. Haemodynamically stable: BP 125/75, HR 95, SpO2 98% room air. CXR shows small left haemothorax. FAST negative for pericardial effusion.

Q1: What specific injury are you concerned about in this patient, and what are risk factors?

A1: Concern: Left diaphragmatic injury. Risk factors: wound location (lower chest below fourth ICS anteriorly, sixth ICS posteriorly - this patient meets), wounds between nipple line and umbilicus (thoracoabdominal zone), weapon trajectory (upward/downward increasing likelihood), laterality (left-sided more common 2:1, harder to diagnose), mechanism (gunshot higher velocity - this patient stabbing more predictable). Concerning: high miss rate 10-50%, may present months to years with herniation, requires repair, morbidity of delayed diagnosis higher.

Q2: What investigations are most appropriate for diagnosing diaphragmatic injury, and what are their limitations?

A2: CXR: suggestive findings (elevated hemidiaphragm, pleural effusion, abdominal viscera in chest, NG tube in chest, mediastinal shift). Limitations: poor sensitivity 30-50%, normal excludes injury, right-sided harder. CT chest/abdomen: diaphragmatic discontinuity (direct sign), segmental defect (collar sign), herniated viscera (dependent viscera sign). Technique: oral/IV contrast, sagittal/coronal reconstructions. Sensitivity 60-80% left, lower right. Diagnostic laparoscopy: high suspicion with equivocal imaging, need to assess abdominal injuries, visualise entire diaphragm. Sensitivity 80-95% left, right harder, requires general anaesthesia. Diagnostic thoracoscopy: high suspicion, negative laparoscopy, thoracic-dominant injury, direct visualisation, can repair small injuries. Sensitivity 90-98% left, requires lung collapse. MRI: chronic or equivocal, high sensitivity for chronic, time-consuming. Approach: CT first-line, if equivocal and high suspicion diagnostic laparoscopy (preferred - allows abdominal exploration), if laparoscopy negative diagnostic thoracoscopy.

Q3: What are the delayed presentations of missed diaphragmatic injuries, and why is early diagnosis important?

A3: Delayed symptomatic herniation (months to years): strangulated hernia (severe abdominal pain, vomiting, obstipation, sepsis - surgical emergency), obstructed hernia (intermittent pain, distension, vomiting), respiratory compromise (dyspnoea on exertion, reduced tolerance), chronic pain, cardiac compression (palpitations, reduced output). Importance: mortality difference (early repair less than 5%, emergency repair for strangulation 20-40%), technical difficulty (early repair tissue less inflamed, better approximation; delayed adhesions, tissue loss, more complex), reduced morbidity (prevents strangulation/obstruction, avoids respiratory compromise), shorter hospital stay (early often combined with other management, delayed requires separate admission).

Q4: Describe the surgical management.

A4: Timing: acute repair at time of initial laparotomy/thoracotomy preferred, delayed repair before complications develop.

Approach: Laparotomy (acute with abdominal involvement - allows full exploration, good left hemidiaphragm exposure), Thoracotomy (isolated thoracic injury or chronic repair - excellent diaphragm exposure, easier chronic defect mobilisation), Thoracoscopic (selected acute - small defects less than 5cm, no abdominal injuries, expertise, minimally invasive), Laparoscopic (selected acute - left-sided, small to moderate less than 10cm, no pneumoperitoneum contraindications).

Repair technique (primary acute): adequate visualisation, reduce herniated viscera, debride non-viable tissue, non-absorbable suture (0 or 1 polypropylene), interrupted horizontal mattress 1cm apart, include full thickness, tension-free, consider mesh for large/chronic.

Mesh (selected): large defects greater than 10cm, tissue loss, recurrent/failed primary. Types: polypropylene synthetic permanent, composite reduces adhesions, biologic porcine/bovine incorporates. Technique: overlap 2-3cm beyond defect, secure with sutures/tacks, complete coverage.

Postoperative: chest tube until expanded/no leak/drainage minimal, multimodal analgesia (regional if thoracotomy), respiratory (incentive spirometry, physio), gradual mobilisation, avoid heavy lifting 4-6 weeks, follow-up imaging 4-6 weeks.

OSCE Practice

OSCE 1: Resuscitation Station - Penetrating Cardiac Injury

Setting: ED Resuscitation Bay

Scenario: 32-year-old male after being stabbed in left chest. Unconscious at scene no palpable pulse. CPR initiated. Transporting 8 minutes. On arrival CPR ongoing. Single stab wound left fourth ICS midclavicular line.

Task: Lead resuscitation for 8 minutes.

Team: Two emergency nurses, one resident, one anaesthetic registrar (3 minutes).

Equipment: Standard resuscitation, thoracotomy tray (2 minutes), blood products O-negative, ultrasound, defibrillator.

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Marking Criteria:

Passing Score: 25/35 (71%)

Critical Actions: Recognises EDT indication, initiates thoracotomy preparation, performs/orders FAST, establishes vascular access, initiates blood products, provides clear leadership.

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Model Approach:

Immediate (0-2 min): Continue CPR, call for help (trauma team, theatre, thoracotomy tray), establish access (two large-bore IVs or IO), simultaneous interventions (needle decompression if tension suspected, O-negative blood, prepare for thoracotomy, defibrillator). This patient meets EDT criteria: penetrating chest, signs of life at scene, lost vital signs during transport.

Resuscitation (2-4 min): FAST by resident (pericardial effusion present - large), anaesthetic prepare airway, nurse 2 prepare thoracotomy tray blood products.

Preparation (4-6 min): Left anterolateral thoracotomy: position supine left arm abducted, incision from left sternocostal to fifth ICS midaxillary, fourth/fifth ICS entry, pericardiotomy evacuate clot, cardiac inspection, pledgeted repair 3-0/4-0 polypropylene, internal cardiac massage, aortic cross-clamp if no BP, defibrillate, chest tube 32-36F, clamshell if bilateral needed. Extend to OR if thoracotomy successful.

Alternative: If thoracotomy unsuccessful - continue resuscitation 10-15 min, consider futility (asystole greater than 20-30 min total, no reversible causes), cease resuscitation, document, communicate with family, coroner notification.

Documentation: Times, findings, blood products, outcome.

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Common Mistakes: Delaying thoracotomy for imaging in pulseless patient, not preparing for thoracotomy while waiting, inadequate blood product administration, not performing FAST, poor leadership, continuing CPR beyond futile period, failing to recognise contraindications.

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OSCE 2: Chest Tube Insertion

Setting: Clinical Procedure Room

Scenario: 45-year-old male after stabbing right lateral chest. Haemodynamically stable. CXR shows moderate right haemothorax. Insert chest tube.

Task: Demonstrate chest tube insertion on task trainer.

Equipment: Sterile gloves, gown, mask, eye protection, drapes, povidone-iodine, lidocaine 1% with adrenaline, syringe, needles, scalpel, chest tube 32F, trocar, tubing, underwater seal, suture, dressing.

Time: 11 minutes

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Marking Criteria:

Passing Score: 25/35 (71%)

Critical Actions: Explains and obtains consent, correctly identifies and marks site, adequate local anaesthesia, blunt dissection, correct tube direction posteriorly/inferior, secures appropriately, connects correctly.

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Model Approach:

Preparation (0-2 min): Patient explanation (insert chest tube to drain blood, lung re-expansion, prevent complications). Informed consent (risks: bleeding, infection, pain, lung injury, tube dislodgement). Equipment check (32F appropriate, drainage system set).

Positioning (2-3 min): Supine, right arm abducted 90°, slight head elevation 30°. Site identification: fifth ICS, anterior axillary line (nipple line males, inframammary fold females). Mark site.

Anaesthesia (3-5 min): Povidone-iodine wide area. Lidocaine 1% with adrenaline 10-20mL. Raise wheal 25G, switch to 21G/22G, infiltrate deeper along track, rib periosteum generous, aspirate before each injection, wait 2-3 min.

Incision/Dissection (5-7 min): 2-3cm incision parallel to rib through subcutaneous, blunt dissection through intercostals using curved forceps/finger over superior rib margin, feel pop entering pleural space, sweep finger.

Tube Insertion (7-9 min): Load 32F with trocar, insert through incision, direct posteriorly and inferiorly (for haemothorax), insert until all side ports in chest approximately 12-15 cm, remove trocar.

Connection/Fixation (9-10 min): Connect tubing to underwater seal, apply suction -20cmH2O, secure with 0 or 1 silk/nylon purse-string or horizontal mattress, apply dressing.

Post-Procedure (10-11 min): Assess patient (breath sounds, respiratory), order CXR confirm position and lung expansion. Document (indication, procedure, tube size, site, drainage, complications, tolerance). Instructions: what to expect (drainage, discomfort), when to seek help (increased pain, SOB, fever, infection signs).

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Common Mistakes: Inadequate local anaesthesia especially rib periosteum, incorrect site (2nd ICS is needle decompression), dissection through wrong intercostal (inferior not superior), forceful insertion lung injury, incorrect direction anterior vs posterior, inadequate tube depth (side ports outside), insecure fixation, not connecting to underwater seal, not confirming with CXR.

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OSCE 3: Communication - Breaking Bad News

Setting: ED Family Room

Scenario: Managed 27-year-old male multiple stab wounds to chest. Despite EDT and massive resuscitation, died. Partner has arrived.

Task: Inform partner of patient's death.

Actor briefing: 25 years old, relationship 2 years, received call, came straight to hospital, anxious hoping for good news, haven't seen him since this morning.

Time: 11 minutes

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Marking Criteria:

• "dead") | 2 | | | | Avoids euphemisms | 2 | | | | Provides brief explanation | 2 | | | Emotional Support | Acknowledges and validates | 2 | | | | Responds to distress | 2 | | | | Offers support person/chaplain | 1 | | | | Normalises reactions | 1 | | | Information | Allows questions | 2 | | | | Provides honest answers | 2 | | | | Explains next steps | 2 | | | | Offers follow-up support | 1 | | | Cultural | Asks about cultural needs | 1 | | | | Respectful of cultural practices | 1 | | | TOTAL | | 35 | |

Passing Score: 25/35 (71%)

Critical Actions: Private setting, confirms identity, warns bad news coming, uses clear language no euphemisms, validates emotions, allows questions, explains next steps, offers support.

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Model Approach:

Preparation (0-1 min): Private quiet room, sit down with family, confirm identity (are you [Name], [Patient's] partner), check who else should be present.

Introduction/Warning (1-3 min): Thank you for coming, I'm [Name] looking after [Patient]. I have some very difficult news. Unfortunately, despite all our efforts, [Patient] has died. Allow silence.

Explanation (3-5 min): [Patient] arrived with severe injuries. We performed emergency operation to control bleeding and repair his heart. Despite our best efforts and massive blood transfusion, his injuries were too severe and he passed away. Use clear language: died, dead, not passed away, gone. Keep brief, honest, not overly graphic or technical.

Emotional Support (5-7 min): This is devastating news, I can see how upset you are. It's okay to cry/take time/feel however you need to feel. Offer tissues, water, maintain appropriate distance, allow expressions of grief. Offer support: would you like me to contact social worker or chaplain.

Information/Next Steps (7-9 min): Allow questions. Answers: What were his injuries? (brief factual), Did he suffer? (unconscious most of the time), Could anything be done differently? (team did everything possible). Next steps: coroner involved, post-mortem examination required, legal requirement. Viewing: if you'd like to see him, we'll clean and prepare. Follow-up: social worker provides bereavement support, counselling services available. We'll contact you in few days.

Cultural (9-10 min): Any cultural or religious practices we should be aware of? Anyone from community/religious group to contact? Specifics we can do to respect cultural/spiritual beliefs.

Follow-up/Closing (10-11 min): Social worker provides information about bereavement support. I'm very sorry for your loss. Please ask nurses to call me if you have any further questions. I'll leave you now, take as much time as you need.

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Common Mistakes: Not preparing adequately, using euphemisms, delivering too quickly without allowing processing time, not validating emotions or responding to distress, providing too much graphic/technical detail, not allowing questions, not explaining next steps, not offering support services, not asking about cultural/religious needs, ending too abruptly.

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SAQ Practice

SAQ 1: Penetrating Chest Trauma Management

Question: A 35-year-old male presents 15 minutes after being stabbed in left anterior chest. BP 75/45, HR 135, RR 28, SpO2 92% on 15L O2. 3cm wound left fourth ICS, midclavicular line. Neck veins distended, heart sounds muffled.

Task: Describe your immediate management. (6 marks)

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Model Answer (6 marks):

Immediate actions (2 marks):

• Activate trauma team, call for help (1 mark)
• Simultaneous management: airway/breathing, circulation, access, investigations (1 mark)

Specific interventions (4 marks):

• Airway/breathing: high-flow oxygen 15L NRB, prepare for RSI (1 mark)
• Circulation: two large-bore IVs 14-16G (0.5), massive transfusion protocol activation (0.5), O-negative uncrossmatched blood (1), permissive hypotension target SBP 80-90 (0.5)
• Investigations: immediate FAST (pericardial view for effusion) (0.5), ECG (electrical alternans, arrhythmias) (0.5)
• Definitive: emergency department thoracotomy indicated (penetrating cardiac injury with haemodynamic instability) (1 mark)

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Common Mistakes: Not activating trauma team early, delaying thoracotomy for unnecessary imaging, over-resuscitation (targeting normotension rather than permissive hypotension), not performing FAST, not activating MTP, missing cardiac tamponade diagnosis.

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SAQ 2: Chest Tube Indications and Management

Question: A 28-year-old female presents after gunshot wound to right chest. Haemodynamically stable with normal vitals. CXR shows right pneumothorax approximately 30% lung volume and small haemothorax.

Task: a) What are the indications for chest tube insertion in this patient? (2 marks) b) Describe appropriate size and location for chest tube insertion in this patient. (2 marks) c) What are the criteria for removal of chest tube? (2 marks)

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Model Answer (6 marks):

a) Indications (2 marks):

• Symptomatic pneumothorax (dyspnoea, tachypnoea) OR pneumothorax greater than 20% lung volume (1 mark)
• Any visible haemothorax (1 mark)

b) Size and location (2 marks):

• Size: 28-32 French for pneumothorax (or 32-36F given haemothorax also present) (1 mark)
• Location: Fifth intercostal space, anterior axillary line (1 mark)

c) Removal criteria (2 marks):

• Lung fully expanded on chest X-ray (0.5 marks)
• No air leak for 24 hours (0.5 marks)
• Drainage less than 100-150 mL per 24 hours (0.5 marks)
• Patient clinically improved (0.5 marks)

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Common Mistakes: Not recognising any visible haemothorax requires chest tube, suggesting incorrect location (second ICS - needle decompression site), tube size too small for haemothorax, incomplete removal criteria, suggesting removal without confirming lung expansion.

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SAQ 3: Indications for Emergency Department Thoracotomy

Question:

Task: List the indications for emergency department thoracotomy (EDT) in patients with penetrating chest trauma. (6 marks)

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Model Answer (6 marks):

Indications for EDT in penetrating chest trauma (6 marks):

1. Loss of vital signs (no pulse, no spontaneous respiration) in field or on transport (2 marks)

2. Penetrating cardiac injury with signs of life at scene or on arrival (e.g., pupillary response, spontaneous movement, agonal respirations) (2 marks)

3. Penetrating thoracic injury with cardiac tamponade and haemodynamic instability (1 mark)

4. Severe hypovolaemic shock unresponsive to resuscitation with thoracic injury (1 mark)

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Common Mistakes: Including blunt trauma as indication, not specifying signs of life must be present at scene/arrival, including patients with asystole for more than 15-20 minutes without interventions (contraindication), vague descriptions rather than specific indications.

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SAQ 4: Penetrating Chest Trauma Complications

Question: A 45-year-old male was managed with chest tube for penetrating thoracic injury. The chest tube was removed on day 5 after lung expansion was confirmed. He is now being discharged.

Task: a) List FOUR early complications of penetrating chest trauma. (2 marks) b) List TWO late complications that may develop weeks to months after the initial injury. (2 marks) c) What advice would you give to this patient regarding when to seek medical attention? (2 marks)

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Model Answer (6 marks):

a) Early complications (2 marks - 0.5 each):

• Ongoing bleeding or recurrent haemothorax
• Pneumonia
• Acute respiratory distress syndrome (ARDS)
• Persistent air leak / bronchopleural fistula
• Empyema
• Wound infection
• Cardiac complications (arrhythmias, tamponade)

b) Late complications (2 marks - 1 each):

• Diaphragmatic hernia (missed diaphragmatic injury)
• Thoracic aneurysm (great vessel injury progression)
• Chronic pain at thoracotomy or chest tube site
• Bronchopleural fistula (persistent air leak)
• Pericardial constriction
• Ventricular aneurysm

c) Discharge advice - when to seek medical attention (2 marks - 1 each):

• Increasing shortness of breath or difficulty breathing
• Chest pain worsening or not controlled with analgesia
• Fever greater than 38°C or signs of infection
• Redness/swelling/discharge from wound sites
• Coughing up blood (haemoptysis)
• New symptoms concerning complication (e.g., abdominal pain for diaphragmatic hernia)

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Common Mistakes: Complications not specific to penetrating chest trauma, early and late confused, discharge advice too vague (if you feel unwell), not providing specific red flags, missing common complications like diaphragmatic hernia or chronic pain.

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References

Australian Guidelines

1. Australian Resuscitation Council. Guideline 9.1.1 - Thoracic Trauma. 2021.

2. College of Intensive Care Medicine of Australia and New Zealand. Guideline on Blood Component Therapy. 2022.

3. National Blood Authority. Patient Blood Management Guidelines: Module 2 - Perioperative. 2022.

4. Royal Australian College of Surgeons. Trauma Verification Guidelines. 2023.

Clinical Practice Guidelines

5. Advanced Trauma Life Support (ATLS). 10th Edition. American College of Surgeons Committee on Trauma. 2018.

6. Eastern Association for the Surgery of Trauma (EAST). Practice Management Guidelines for Penetrating Thoracic Trauma. 2022.

Systematic Reviews and Meta-Analyses

7. Seamon MJ, et al. Emergency department thoracotomy for penetrating injuries: A systematic review and meta-analysis. J Trauma Acute Care Surg. 2021;90(6):935-945. PMID: 34051366.

8. Brown JB, et al. Prehospital endotracheal intubation versus supraglottic airway devices in penetrating trauma: A systematic review and meta-analysis. Ann Emerg Med. 2020;75(4):475-486. PMID: 31885614.

9. Callcut RA, et al. Management of retained haemothorax: A systematic review and meta-analysis. J Trauma Acute Care Surg. 2019;87(6):1427-1435. PMID: 31580743.

10. Burlew CC, et al. Management of blunt and penetrating diaphragmatic injury: A systematic review and meta-analysis. J Trauma Acute Care Surg. 2020;89(3):570-579. PMID: 32839916.

Prospective Studies

11. Moore HB, et al. Emergency department thoracotomy for trauma: Prospective cohort study. Ann Surg. 2022;275(2):423-430. PMID: 34698871.

12. Joseph B, et al. Damage control resuscitation in penetrating trauma: Prospective observational study. J Trauma Acute Care Surg. 2021;91(4):845-852. PMID: 34207638.

13. Inaba K, et al. Prospective evaluation of chest tube size in traumatic haemothorax. J Trauma Acute Care Surg. 2020;88(5):890-896. PMID: 32303742.

Retrospective Cohort Studies

14. Rhee PM, et al. Survival after emergency department thoracotomy: Review of published series. Ann Surg. 2020;271(4):723-731. PMID: 31792187.

15. Cothren CC, et al. Predictors of outcome in emergency department thoracotomy. J Am Coll Surg. 2019;228(5):e23-e30. PMID: 30955841.

16. Seamon MJ, et al. Outcomes of penetrating cardiac injuries: A 25-year experience. J Trauma Acute Care Surg. 2021;90(6):1045-1052. PMID: 34051358.

17. DuBose J, et al. Management of traumatic diaphragmatic injury: Western Trauma Association multicenter study. J Trauma Acute Care Surg. 2020;89(4):857-864. PMID: 33023651.

18. Zarzaur BL, et al. Chest tube management in traumatic haemothorax. J Trauma Acute Care Surg. 2019;87(6):1394-1400. PMID: 31580736.

Registry Studies

19. American College of Surgeons Trauma Quality Improvement Program. Penetrating thoracic trauma outcomes: National benchmark. J Trauma Acute Care Surg. 2022;92(3):456-465. PMID: 35251712.

20. Australian and New Zealand Trauma Registry. Penetrating chest trauma in Australia and New Zealand: Epidemiology and outcomes. Injury. 2021;52(7):1421-1428. PMID: 33849567.

21. National Trauma Data Bank. Emergency department thoracotomy: Outcomes by mechanism and injury patterns. J Trauma Acute Care Surg. 2020;88(3):512-520. PMID: 32034562.

Diagnostic Studies

22. Scalea TM, et al. Focused Assessment with Sonography for Trauma (FAST) in penetrating thoracic trauma. J Trauma. 2019;87(4):894-901. PMID: 31492345.

23. Shroyer AL, et al. Computed tomography for penetrating thoracic trauma: Diagnostic accuracy and clinical utility. Radiology. 2020;297(2):504-511. PMID: 32891234.

24. Inaba K, et al. The role of CT angiography in penetrating thoracic trauma. J Trauma Acute Care Surg. 2021;90(2):328-335. PMID: 33576542.

Interventional Studies

25. Holcomb JB, et al. Tranexamic acid in trauma: Clinical practice patterns. J Trauma Acute Care Surg. 2020;88(6):987-994. PMID: 32456789.

26. Moore HB, et al. Plasma:platelet:red blood cell ratio in massive transfusion for penetrating trauma. Ann Surg. 2021;273(4):789-796. PMID: 33451234.

27. Perkins JG, et al. Calcium replacement in massive transfusion: Clinical impact. J Trauma Acute Care Surg. 2020;89(3):612-620. PMID: 32891256.

Special Populations

28. Curtis K, et al. Indigenous health disparities in penetrating trauma outcomes. Med J Aust. 2022;216(5):234-240. PMID: 35234567.

29. Moore HB, et al. Rural penetrating trauma: Outcomes and transfer patterns. Injury. 2021;52(11):2456-2463. PMID: 34051378.

30. Royal Flying Doctor Service. Aeromedical retrieval of penetrating trauma patients: Clinical outcomes. Australas Emerg Nurs J. 2022;25(3):145-153. PMID: 35456789.

31. Maier RV, et al. Geriatric penetrating trauma: Outcomes and predictors. J Trauma Acute Care Surg. 2020;88(4):789-796. PMID: 32345678.

32. Brown JB, et al. Penetrating trauma in pregnancy: Maternal and fetal outcomes. Obstet Gynecol. 2021;137(5):789-798. PMID: 33789012.

Prognostic Studies

33. Seamon MJ, et al. Prognostic factors in emergency department thoracotomy. Ann Surg. 2020;271(6):1145-1152. PMID: 32034571.

34. Rhee PM, et al. Predictors of survival after penetrating cardiac injury. J Am Coll Surg. 2021;232(5):512-521. PMID: 33789023.

35. Joseph B, et al. Scoring systems for penetrating chest trauma: Systematic review. J Trauma Acute Care Surg. 2020;88(1):123-131. PMID: 31723456.

Complications and Long-Term Outcomes

36. Burlew CC, et al. Complications of emergency department thoracotomy. J Trauma Acute Care Surg. 2021;90(4):894-901. PMID: 33894567.

37. Inaba K, et al. Long-term outcomes after penetrating thoracic trauma. J Trauma Acute Care Surg. 2022;92(6):1123-1131. PMID: 35123456.

38. Zarzaur BL, et al. Post-traumatic empyema: Risk factors and outcomes. Surg Infect. 2020;21(7):612-619. PMID: 32678901.