Key Messages

The Victorian State Trauma System (VSTS) provides support and retrieval services for critically injured patients requiring definitive care, transfer and management. This thoracic trauma guideline aims to provide evidence-based advice on the initial management and transfer of major trauma patients who present to Victorian health services with thoracic injuries.

This guideline is developed for all clinical staff involved in the care of trauma patients in Victoria. It is intended for use by frontline clinical staff that provide early care for major trauma patients; those working directly at the Major Trauma Services (MTS) as well as those working outside of a MTS.

These guidelines provide the user with accessible resources to provide initial care for critically injured patients with thoracic trauma in an effective and confident manner. The guideline has been assessed utilising the AGREEII methodology for guideline development and is under the auspice of the Trauma System Advisory Committee (TSAC).⁽¹⁾

Clinical Emphasis Points

• Thoracic trauma is a common injury in the multi-trauma patient and a significant cause of mortality and morbidity.
• Thoracic trauma can result in immediately life-threatening injury; such injuries need to be identified, assessed and managed promptly to ensure a positive outcome for the patient.
• Two common reversible causes in traumatic cardiac arrest are found within the thoracic cavity; tension pneumothorax and pericardial tamponade.
• Patients who present with penetrating or blunt thoracic injuries and are pulseless but with myocardial mechanical activity on ultrasound and/or electrical activity may be candidates for resuscitative thoracotomy in the emergency department.
• Non life-threatening injuries can be subsequently addressed in the secondary survey with more in-depth physical examination and monitoring.
• Adequate analgesia is essential to prevent secondary insults due to hypoventilation and assists with coughing and chest physiotherapy.
• Appropriate ventilatory support settings must be considered especially where poor lung compliance and pulmonary contusions are involved.
• Adult Retrieval Victoria (ARV), can facilitate a three-way conversation for advice on patient management with a specialist from a major trauma service. This should be considered early, particularly for patients with:
  • Flail chest
  • Multiple rib fractures
  • Penetrating injury
  • Significant pulmonary contusion
  • Large pneumothorax, or
  • Any critical or life-threatening thoracic injury (see below).
• The presence of thoracic trauma in the paediatric and elderly populations should raise significant concern and must be managed appropriately.
  
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