Key Messages

The Victorian State Trauma System provides support and retrieval services for critically injured patients requiring definitive care, transfer and management. This thoracic trauma guideline provides 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 Service (MTS) as well as those working outside of a MTS. These thoracic management guidelines provide up-to-date information for frontline healthcare clinicians.
These guidelines provide the user with accessible resources to effectively and confidently provide early care for critically injured thoracic patients. The guideline has been assessed utilising the AGREEII methodology for guideline development and is under the auspice of the Victoria State Trauma Committee (VSTC).¹

Clinical Emphasis Points

• Thoracic trauma is a common injury in the multi-trauma patient and a significant cause of mortality. Life threatening injuries need to be addressed promptly to ensure a positive outcome for the patient.
• Thoracic trauma can result in immediately life-threatening injury, as well as delayed morbidity and mortality.
• Early recognition with prompt diagnosis and treatment of thoracic trauma is essential to prevent both early and delayed morbidity and mortality.
• Suboptimal initial management of thoracic trauma can be associated with significant complications and morbidity.
• Life threatening injuries identified in the primary survey need to be addressed before moving on to the secondary survey.
• Patients who present with penetrating or blunt thoracic injuries and are pulseless but with myocardial electrical activity may be candidates for resuscitative thoracotomy in the emergency department.
• Delayed life threatening injuries can be addressed in the secondary survey with more in-depth physical examination and monitoring.
• Appropriate ventilatory support settings must be considered especially where poor lung compliance and pulmonary contusions are involved.
• Adequate analgesia is essential to prevent secondary insults due to hypoventilation and assists with coughing and chest physiotherapy.
• 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 in the course of patient care, 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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