Thoracic trauma

Konstantīns Markevičs MF5

• The skeletal and muscular shell of the thorax encloses the heart and lungs, powers breathing, and is the mechanical platform for arm and neck motion.

• It is bounded anteriorly by the sternum and ribs, laterally and posteriorly by the ribs, and supported posteriorly by the spine.

• The inferior boundary is the diaphragm and rib margins. Superiorly, it is bounded by the clavicles and soft tissues of the neck. The thoracic wall includes the bodies of the 12 thoracic vertebrae, the 12 pairs of ribs, and the sternum.[1]

Epidemiology[2]

• Thoracic injury directly accounts for 20 to 25% of deaths from trauma, resulting in more than 16,000 deaths annually in the United States.

• Early deaths (within the first 30 minutes to 3 hours) resulting from thoracic trauma are often preventable. Causes of these include tension pneumothorax, cardiac tamponade, airway obstruction, and uncontrolled hemorrhage.

• Among victims sustaining thoracic trauma, approximately 50% will have chest wall injury: 10% minor, 35% major, and 5% flail chest injuries.

Prehospital management

• The principal aim of the primary survey is to identify and treat immediately life-threatening conditions. The life-threatening chest injuries are[3]:– Massive hemothorax– Tension pneumothorax– Open pneumothorax– Flail chest– Pericardial tamponade

• The secondary survey is a more detailed and complete examination, aimed at identifying all injuries and planning further investigation and treatment. Chest injuries identified on secondary survey and its adjuncts are[4]:– Rib Fractures – Pulmonary contusion– Simple pneumothorax– Simple haemothorax– Blunt aortic injury– Blunt myocardial injury

The prehospital approach to chest injury management[5]

• Beware of distracting injuries particularly in patients with multiple or dramatic injuries.

• Consider whether the casualty requires immediate evacuation to hospital

• Assessing the mechanism of injury and context (eg, time to hospital and method of transfer) may also guide the practitioner between the balance of staying on scene allowing exposure, assessment and intervention versus rapid transfer.

• Assess airway with cervical spine stabilisation, breathing and circulation.

• In the presence of catastrophic exsanguinating haemorrhage, rapid external haemorrhage control should be achieved before airway management.

• Recognition of the mechanism of chest injury is essential to guide subsequent assessment and treatment, as severe chest injuries (especially mediastinal injury) can occur in the absence of obvious external injury.

Prehospital assessment[5]

• Look (important yet often missed)– Respiratory rate and pattern. Count for 1 min. Reassess at regular intervals as

this will be the first indicator of deterioration of the patient.– Chest wounds (especially sucking chest wounds) or bruising.– Movement of the chest wall. – Neck wounds, surgical emphysema or neck swelling. The swelling of

subcutaneous tissues due to the presence of air within the tissues suggests a pneumothorax is likely to be present. Penetrating neck injuries may be associated with pneumothorax or haemothorax.

– Venous engorgement. This is an inconsistent sign especially if the patient has hypovolaemia and may only be visible if the cervical collar is removed to expose the patients neck.

– Haemoptysis may indicate a tracheobronchial injury or a lung contusion. However, it may simply result from a bleeding facial injury or epistaxis expectorated from the pharynx.

• Feel– Swelling– Crepitus indicating surgical emphysema.– Chest wall tenderness or fractures– Laryngeal crepitus– Deviation of the trachea indicating tension pneumothorax (a late sign)– Percussion should be performed if ambient noise allows and skill base

permits.– Examination of the back and armpits is mandatory to prevent missed

posterior or lateral chest injuries.• Listen

– Auscultation is often difficult due to location and noise. It will only be of benefit if the environment permits and the practitioner is trained and competent in interpreting the signs on auscultation.

– The lateral chest and anterior armpit should be auscultated to avoid misinterpretation of transmitted sound from the contralateral chest.

[5]

[6]

[3]

• Minimum standards of observation[5]– All patients should have recorded:– Respiratory rate– Peripheral (radial) pulse rate– Conscious level—AVPU (Alert, responds to Voice, responds to Pain,

Unresponsive)– and in addition if skills permit:– Pulse oximetry– Blood pressure– Conscious level—Glasgow Coma Scale– ECG monitoring.

• The patient should be reassessed every 10 min or whenever there appears to be a change in the patient's clinical status.

Interventions[5]

• Oxygen high flow through non rebreath mask (15 l/min).‐ ‐• Cover open wounds of the chest. The Asherman chest seal is

recommended, as three sided dressings are often ineffective.‐• Stop external haemorrhage from chest wounds by dressings

and direct pressure.• Manual splinting of flail chests (particularly for the short

term in the absence of analgesia). Methods of splinting include direct pressure applied by the hand of the patient or practitioner; positioning the patient laying on the flail segment; or a 500 ml bag of fluid taped over the area of flail.

• Relieve a tension pneumothorax by needle decompression.• Rapid sequence induction of anaesthesia if indicated • If the patient is shocked, or has multiple injuries, then

immediate transfer to hospital is indicated with cannulation and intravenous fluid administration en route.

• Unless transfer times are prolonged, technician crews should not await the arrival of paramedic or medical support before urgent transfer. When prolonged transfer times are expected consideration should be made to the use of helicopter transport or a rendezvous point to meet paramedic or medical support on route to hospital.

Analgesia[5]

• Analgesia should be used routinely unless the patient has a time critical injury. The choice of analgesia depends on the skill level of the practitioner and includes:

• Manual splinting or positioning with support from pillows• Intravenous morphine (consider additional antiemetic)• Intravenous Ketamine• Intranasal diamorphine can be considered in children• Local anaesthetic injection for intercostal nerve blocks• Entonox should only be used where the above options are

unavailable. It is difficult to administer effectively if there is poor inspiratory effort. The use of entonox is associated with decreased oxygen delivery, and the risk of exacerbating a pneumothorax.

Positioning[5]

• If placed on one side this should be good side down as ventilation–perfusion is optimal one third up the chest. If there is a risk of airway contamination (blood in the airway or vomiting) then the injured side of the chest should be positioned down.

• Consider lying the patient on the side of a flail to allow splinting and analgesia.• If there is an anterior flail chest then manual splinting of the chest may need to be

maintained• Note that the ability to reposition is limited in a moving ambulance• In an isolated chest injury the ideal position is sitting up. Patients self splinting ‐

using their own chest muscles will be reduced if they lay flat. Avoid long periods positioned supine on a spinal board. If the patient is conscious, with no neck pain and no distracting pain or injuries, patients who wish should be allowed to sit up.

• Unconscious patients with the appropriate mechanism of injury should have full spinal immobilisation.

Alert and handover [5]

• The information for the alert should include:– Mechanism of injury– Suspected injuries– Current observations including respiratory rate,

pulse and blood pressure– Treatment given– Expected time of arrival.

Rib fractures

• Rib fractures (RF) are the most frequent injuries after TT, and they are considered an important indicator of severity, as they reflect a great quantity of energy absorbed by the chest wall.

• RF are more frequent between the 3rd and 9th ribs.• In the lower ones (lower than the 8th rib), the associated

lesions may be situated at the abdominal level. • Those of the first three ribs generally indicate serious TT

with possible associated mediastinal, neurological, vascular or extrathoracic lesions.[7]

• With 3 RF or more, the associated extrathoracic lesions, the rate of complications and mortality increase significantly, therefore this number of lesions is considered an indicator for hospitalization. This rate increases in multiple and in bilateral RF, when it is recommended that the patient be admitted to an Intensive Care Unit (ICU).

• Mortality can reach 15% in cases of more than 6 RF. [7]

Diagnostic strategies[7]

• Chest x-ray films often do not demonstrate the presence of rib fractures but are of greatest value in suggesting significant intrathoracic and mediastinal injuries.

• Upright posteroanterior chest radiograph has a high yield in detecting rib fractures or their complications compared with other views.

• CT scans are significantly more effective than chest x-ray examination in detecting rib fractures

• 50% of single-rib fractures are not seen on the initial x-ray film.

• A CT scan should be considered based on the mechanism of injury, physical examination, hemodynamic and respiratory parameters, abnormal findings on chest x-ray examination (especially widened mediastinum), or clinical evidence of multiple rib fractures, especially of the lower ribs (which may herald a splenic or hepatic injury).

Management• Adequate pain relief and the maintenance of pulmonary

function. • Oral pain medications are usually sufficient for young and healthy

patients. Continuing daily activities and deep breathing should be stressed to ensure ventilation and prevent atelectasis.

• It is helpful to take pain medications and wait 30 to 45 minutes before performing deep breathing exercises, perhaps with an incentive spirometer.

• Binders, belts, and other restrictive devices should not be used because although they can decrease pain, they also promote hypoventilation with subsequent atelectasis and pneumonia.[7]

• Patients with 3 or more fractured ribs, despite the lack of other traumatic injuries, should likely be hospitalized to receive aggressive pulmonary therapy and appropriate effective analgesia.

• Elderly patients with 6 or more fractured ribs should be treated in intensive care units.

• Older patients will probably require narcotic preparations, but care should be taken to avoid oversedation because of the potential for respiratory failure.[7]

• Intercostal nerve blocks with a long-acting anesthetic such as bupivacaine with epinephrine may relieve symptoms up to 12 hours with excellent results.

• Such nerve blocks are achieved by administration of 1 or 2% lidocaine or 0.25% bupivacaine along the inferior rib margin several centimeters posterior to the site of the fracture.

• One rib above and one rib below the fractured rib should also be blocked for optimal analgesia.

• Other alternatives for hospitalized patients include patient-controlled analgesia, parenteral opiates, and thoracic epidural analgesia.[7]

Clinical course[7]

• Most rib fractures heal uneventfully within 3 to 6 weeks, usually discomfort gradual decrease during this period

• Analgesics are usually necessary during the first 1 or 2 weeks. • However, in addition to the complications of

hemopneumothorax, atelectasis, pulmonary contusion, and pneumonia, rib fractures can result in post-traumatic neuroma or costochondral separation.

• Special attention should be paid to patients with displaced rib fractures, who may develop delayed hemorrhage resulting in death, typically from intercostal artery tears that clot off and then rebleed.

Flail chest

• Flail chest results when three or more adjacent ribs are fractured at two points, allowing a freely moving segment of the chest wall to move in paradoxical motion

• It can also occur with costochondral separation or vertical sternal fracture in combination with rib fractures.

• Because of its common association with pulmonary contusion, it is one of the most serious chest wall injuries.[7]

[2]

Diagnostic strategies[7]

• Multiple rib fractures can usually be identified on chest x-ray films.

• CT scan is much more accurate than plain films in detecting the presence and extent of underlying injury and contusion to the lung parenchyma.

• It is used routinely in some centers for all patients with major chest trauma.

[4]

Management[7]

• Oxygen administration .• Cardiac and oximetry monitors applied if available.• Observation for signs of an associated injury such

as tension pneumothorax.• A 12-lead ECG and cardiac enzymes • Consideration of echocardiogram for significant

dysrhythmias, high-grade blocks, or hemodynamic instability unexplained by other causes such as hemorrhage.

• The cornerstones of therapy include aggressive pulmonary physiotherapy, effective analgesia, selective use of endotracheal intubation and mechanical ventilation, and close observation for respiratory compromise.

• Respiratory decompensation is primary indication for endotracheal intubation and mechanical ventilation.

• Obvious problems, such as hemopneumothorax or severe pain, should be corrected before intubation and ventilation are presumed necessary. In fact, in the awake and cooperative patient, noninvasive continuous positive airway pressure (CPAP) by mask may obviate the need for intubation.

• Adequate analgesia is of paramount importance in patient recovery and may contribute to the return of normal respiratory mechanics.

• Patients without respiratory compromise generally do well without ventilatory assistance.

• Several studies have found that patients treated with intercostal nerve blocks or high segmental epidural analgesia, oxygen, intensive chest physiotherapy, careful fluid management, and CPAP, with intubation reserved for patients in whom this therapy fails, have shorter hospital courses, fewer complications, and lower mortality rates.

• Avoidance of endotracheal intubation, particularly prolonged intubation (preventing pulmonary morbidity, risk of pneumonia).

• There is also evidence that early operative internal fixation of the flail segment results in a speedier recovery, decreased complications, and better cosmetic and functional results, and that it is cost-effective.

• The mortality rate associated with flail chest is between 8 and 35% and is directly related to the underlying and associated injuries.

• Those who recover from flail chest may develop long-term disability with dyspnea, chronic thoracic pain, and exercise intolerance.

Pneumothorax and Hemothorax[6]Diagnosis

• The differential diagnosis for tension pneumothorax includes cardiac tamponade, massive hemothorax, and right mainstem intubation with left lung collapse. All will produce respiratory distress, hypotension, and tachycardia.

• Cardiac tamponade results in diminished heart sounds with normal breath sounds and a midline trachea.

• Massive hemothorax produces decreased or absent unilateral breath sounds and dullness to percussion.

• Chest tube insertion confirms the diagnosis. • Bilateral needle thoracostomy should be performed when the patient

is in distress, even if the diagnosis is uncertain. A rush of air confirms the diagnosis of tension pneumothorax. Chest tubes must be placed after needle decompression.

• A chest radiograph can confirm the diagnosis of simple pneumothorax and hemothorax. A distance of 1 cm or one fingerbreadth between the chest wall and visceral pleural line correlates with a small, 10% to 15% pneumothorax.

• Anything larger requires immediate chest tube insertion. • Clinically significant pneumothorax should be evident on

standard chest radiographs. The chest CT scan is more sensitive in visualizing pneumothorax; it often detects small occult pneumothoraces, which require close monitoring.

• In an upright patient, a hemothorax appears as a fluid layer in the affected hemithorax.

• Early collections are noted to blunt the costophrenic angles on the AP and lateral radiographic views.

• Hemopneumothorax has a fluid layer with a flat superior border, in contrast to the round meniscus of an isolated hemothorax. Decubitus views better demonstrate a small hemothorax.

• An extended focused assessment with sonography for trauma (FAST) scan can diagnose pneumothorax and hemothorax with higher sensitivity than portable chest radiography can in experienced hands.

Treatment[6]

• Tension pneumothorax and open pneumothorax are both clinical diagnoses that require immediate treatment with needle thoracostomy followed by tube thoracostomy, even when based on clinical evaluation, before radiographic confirmation.

• All suspicious open chest wounds should be covered with petrolatum gauze secured on three sides to prevent the entry of air during inspiration and allow the exit of air during expiration.

• Postprocedure radiographs should be obtained to confirm placement, drainage of air and blood, and reexpansion of lung. Prophylactic antibiotics with chest tube insertion do not reduce the risk for empyema or pneumonia.

• Operating room thoracotomy is indicated:– for patients with massive hemothorax (initial drainage of 1.5

to 2 L of blood), – persistent bleeding of more than 200 mL/hr for 4 hours, – and persistent hypotension or instability despite blood

replacement. • Autotransfusion should be performed in patients with

massive hemothorax or persistent significant bleeding. It is prudent to prepare for autotransfusion early because most blood loss occurs at the time of initial chest tube insertion.

Pericaridal tamponade[6]

Signs and symptoms

• Classically but uncommonly exhibit the Beck triad of hypotension, jugular venous distention, and muffled heart sounds.

• Most patients will have at least one of these signs, with all three appearing only briefly before cardiac arrest.

• More frequently, patients either appear relatively stable or are in extremis. • Stable-appearing patients have small wounds in the pericardium that allow

intermittent decompression of the accumulated blood.• Patients with more rapid accumulation are panic-stricken, appear to be in

severe respiratory distress, and often have needle thoracostomy performed for presumed tension pneumothorax.

• In these patients, agitation, tachycardia, and hypotension predominate before progressing to obtundation, bradycardia, and pulseless electrical activity.

Differential Diagnosis and Medical Decision Making[6]

• US subxiphoid view. • Pericardial fluid with diastolic collapse of the right atrium

and ventricle is diagnostic of pericardial tamponade. • Any pericardial effusion in unstable trauma patients with

equal bilateral breath sounds signals tamponade requiring immediate operative intervention.

• Sensitivity of FAST scans approaches 100% for hemopericardium, but false-negative results may occur when blood drains rapidly into the thorax (inpatients with small anterior stab wounds and persistent left hemothorax despite tube thoracostomy).

• Initial ECG. Electrical alternans, low voltage, and PR-segment depression are specific but not sensitive for the diagnosis of pericardial effusion(more likely in chronic effusion).

• Acute traumatic pericardial effusion resulting in tamponade does not change the size of the heart on the chest radiograph.

• Chest RTG to identify other injuries.• Normal findings on the ECG and chest radiograph do not

rule out traumatic pericardial effusion or tamponade.

Subxiphoid view of a focused assessment with sonography for trauma scan showing traumatic hemopericardium (arrows) .

LV , Left ventricle.(From Mandavia DP, Joseph A. Bedside echo in chest trauma. Emerg Med Clin North Am

2004;22:601-19.)

Treatment[6]

• Central venous line for volume infusion, monitoring of central venous pressure.

• The injured hemithorax is preferred for central line placement to avoid iatrogenic complications in the uninjured side (exception is a patient with obvious injury to the clavicle and suspected injury to the subclavian vein).

• Aggressive fluid resuscitation is mandatory for patients with suspected pericardial tamponade to maximize cardiac filling pressure and cardiac output.

• Elevated central venous pressure in persistently hypotensive and tachycardic trauma patients suggests impending tamponade.

• Pericardiocentesis with catheter placement should be performed in patients with deteriorating vital signs.

• Pericardiocentesis - diagnostic and temporizing measure, but is never a replacement for thoracotomy and definitive repair of the injury.

• Ultrasonography or ECG-guided pericardiocentesis is preferred, if available.

• Thoracotomy is reserved for patients with cardiac tamponade who are in cardiac arrest or impending arrest.

• The likelihood of functional survival after ED thoracotomy is greatest for victims of stab wounds with isolated cardiac injury who have signs of life on ED arrival.

• At the trauma center, thoracotomy is performed on victims of penetrating trauma who experienced cardiac arrest in the ED or within 10 minutes of arrival at the ED and on blunt trauma patients who experienced cardiac arrest in the ED.

• In the ED without surgical support, thoracotomy is best performed by a skilled EP only on patients with thoracic stab wounds or isolated gunshot wounds who lost signs of life in the ED or within 10 minutes of arrival in the ED.

• In all other cases, ED thoracotomy should be performed only if a qualified surgeon is present or immediately available

Pulmonary contusion[2]

Clinical signs

• Include dyspnea, tachypnea, cyanosis, tachycardia, hypotension, and chest wall bruising.

• Hemoptysis may be seen sometime during the patient’s course, and moist rales or absent breath sounds may be heard on auscultation.

• Palpation of the chest wall commonly reveals fractured ribs.

• If flail chest is discovered, pulmonary contusion is commonly present.

Diagnostic strategies

• In initial x-ray studies may mask the contusion. • Typical radiographic findings begin to appear

within minutes of injury and range from patchy, irregular, alveolar infiltrate to frank consolidation.

• Typical radiographic findings begin to appear within minutes of injury and range from patchy, irregular, alveolar infiltrate to frank consolidation .

• Usually, these changes are present on the initial examination, and they are almost always present within 6 hours.

• Ddx - acute respiratory distress syndrome (ARDS). The contusion usually manifests within minutes of the initial injury, is usually localized to a segment or a lobe, is often apparent on the initial chest study, and tends to last 48 to 72 hours.

• ARDS is diffuse, and its development is usually delayed, with onset typically between 24 and 72 hours after injury.

• CT scans have been shown to detect twice as many pulmonary contusions as plain radiographs.

• Occult pulmonary contusions are those that are visible only on CT scan, not plain radiographs, and usually involve more than 20% of the lung volume.

• These “occult” pulmonary contusions are not associated with a worse clinical outcome as compared with blunt trauma patients without pulmonary contusion.

• CT – valuable to identify a pulmonary contusion in the acute phase, helpful to further define the extent of the contusion and to identify other thoracic injuries

• Arterial blood gases • A low partial pressure of oxygen (Po2) alone

may be reason to suspect pulmonary contusion.

Treatment[2]

• Treatment for pulmonary contusion is primarily supportive.• When only one lung has been severely contused and has caused significant

hypoxemia, consideration should be given to intubating and ventilating each lung separately with a dual-lumen endotracheal tube and two ventilators.

• This allows for the difference in compliance between the injured and the normal lung and prevents hyperexpansion of one lung and gradual collapse of the other.

• Intubation and mechanical ventilation should be avoided if possible because they are associated with an increase in morbidity, including pneumonia, sepsis, pneumothorax, hypercoagulability, and longer hospitalization.

• But the need for mechanical ventilation increases significantly when the area of pulmonary contusion exceeds 20% of total lung volume.

• Certain patients may benefit from a trial of noninvasive positivepressure ventilation with BPAP or CPAP to avoid intubation and mechanical ventilation.

• In severely injured patients with extensive pulmonary contusions and the development of ARDS with severe hypoxia refractory to conventional therapy, some small studies suggest a possible role for extracorporeal membrane oxygenation.

• Certain procedures may ameliorate the pulmonary contusion, including the restriction of intravenous fluids to maintain intravascular volume within strict limits and aggressive supportive care consisting of vigorous tracheobronchial toilet, suctioning, and pain relief. These maneuvers may preclude the need for ventilator support and allow a more selective approach to flail chest and pulmonary contusion.

• Colloids are not recommended for use in treating these patients.

• Pneumonia is the most common complication of pulmonary contusions, and it significantly worsens the prognosis.

• It develops insidiously, especially in patients treated with prophylactic antibiotics. Antibiotics should be reserved for use with specific organisms rather than given prophylactically.

Left Main Bronchus Rupture due to Blunt Trauma Necessitating Pneumonectomy in

a 6-year-old Boy: A Case Report

• Abedullah Abdolhamid Amouei1 , Saeed Aghapour2 , Mohammad Hossein Khosravi Mashizi2

• 1Associate Professor of Pediatric Surgery, University of Medical Sciences, Rafsanjan, Iran 2Medical Student, University of Medical Sciences, Rafsanjan, Iran

• On 14th April 2013, a 6-year-old boy who fell down from a pickup truck was admitted to the emergency department of the Ali-Ebn-Abitaleb Hospital in Rafsanjan.

• On arrival, the patient was very agitated, briefly cyanotic and had severe respiratory distress.

• Glasgow Coma Scale score of 13 • Vital signs were as follows: pulse rate 120/min,

blood pressure 105/65 mm Hg, respiratory rate 40/min and oxygen saturation was 79-80% by oxygen mask.

On physical examination

• decreased excursion of the left hemithorax,• ipsilateral diminished breath sounds,• right tracheal deviation,• and severe thoracic subcutaneous

emphysema.

• A diagnosis of tension pneumothorax was made and tube thoracostomy was performed.

• Continuous and massive air leak was observed after thoracostomy.

• Respiratory distress subsided after tube thoracostomy and oxygen saturation level increased up to 98%.

• The initial chest X-ray and thorax computed tomography (CT) scan demonstrated a left pneumothorax and complete collapse of the left lung.The patient was admitted to the intensive care unit (ICU).

• 2nd day of admission - tube thoracostomy was connected to the negative pressure due to failure of pulmonary re-expansion.

• Although the air leak stopped after 4 days, the involved lung failed to expand and accordingly other pathologic conditions including severe bronchial injuries or bronchial foreign body were suspected. Bronchoscopy was performed for further evaluation.

• Bronchoscopy: – A piece of bronchial tissue was observed at the

distal left main bronchus. – Bronchial cartilage at the proximal end was

exposed after removal of the ablated piece of bronchus which was suggestive of bronchial rupture.

• A left posterolateral thoracotomy was undertaken through the fifth intercostal space. – Little amount of serosanguinous secretions and

some fibrin clots were observed within the pleural cavity.

– The left lung was completely collapsed without any ventilation and apparent tissue injuries.

– The left main bronchus was completely transected and separated 1.5 cm distal to the carina. There was a 1 cm gap between the two bronchial ends.

– There was also a longitudinal tear in the proximal end of the transected left main bronchus. The longitudinal rupture was repaired by the sutures of 5/0 prolene; however, the diameter of lumen decreased up to 50%.

– Since the bronchial stenosis could result in complications such as recurrent pneumonia, bronchiectasis and atelectasis, and finally growth disorder in children, therefore, pneumonectomy was preferred.

• After ligation of the pulmonary hilum vessels, pneumonectomy was performed and tube thoracostomy was inserted.

• The patient was extubated 24 hours after surgery and discharged from the hospital 6 days after operation.

Conclusions

• Injuries to the major airways are uncommon in children.

• Nearly all are caused by blunt trauma.• Bronchoscopy is indicated for failure of

reexpansion of a pneumothorax in patients with blunt chest trauma.

• In patients with bronchial rupture and when repair is associated with stenosis, pneumonectomy, especially in children, can be considered.

Resources1. AMA Citation

LeBlond RF, Brown DD, Suneja M, Szot JF. The Chest: Chest Wall, Pulmonary, and Cardiovascular Systems; The Breasts. In: LeBlond RF, Brown DD, Suneja M, Szot JF. eds. DeGowin’s Diagnostic Examination, 10e. New York, NY: McGraw-Hill; 2015.http://accessmedicine.mhmedical.com.db.rsu.lv/content.aspx?bookid=1192&Sectionid=68667383. Accessed October 11, 2015.

2. http://www.slremeducation.org/wp-content/uploads/2015/02/Chapter-45.-Thoracic-Trauma.pdf

3. http://www.merckmanuals.com/professional/injuries-poisoning/thoracic-trauma/overview-of-thoracic-trauma

4. http://www.trauma.org/archive/thoracic/CHESTintro.html5. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2660039/6. https://www.clinicalkey.com.db.rsu.lv/#!/content/book/3-s2.0-B97814377354820007817. http://www.archbronconeumol.org/en/guidelines-for-the-diagnosis-and/articulo/90000612/