[Emergency thoracotomy]

OBJECTIVE

To determine indications for emergency (immediate and urgent) thoracotomies in cases of penetrating and blunt chest traumas.

METHODS

We performed retrospective analysis of treatment methods and results, achieved in 2927 patients treated for chest traumas in 1987-2000.

RESULTS

Algorithms for decision making in surgical management of chest traumas are drawn. Indications for emergency (immediate and urgent) thoracotomies are determined. Immediate thoracotomy was performed in 17.2% and 0.2% of patients, suffering from penetrating and blunt chest trauma respectively. Urgent thoracotomy underwent 7.6% due to penetrating and 2.7% due to blunt chest trauma. Postoperative mortality rate was much higher after immediate (20.0%) and urgent (10.9%) thoracotomy performed due to blunt chest traumas. In cases of penetrating chest traumas postoperative mortality rate was 3.3% and 3.0% after immediate and urgent thoracotomies respectively.

CONCLUSIONS

The effectiveness of surgical treatment of chest traumas depends on logical determination of indications for immediate or urgent thoracotomies. They should be undertaken in cases of severe damage of chest wall and/or internal organs and dangerous pathological syndromes.

Should helical CT scanning of the thoracic cavity replace the conventional chest x-ray as a primary assessment tool in pediatric trauma? An efficacy and cost analysis

BACKGROUND/PURPOSE

Findings from studies in the trauma literature suggest that thoracic computed tomography (TCT) scanning should replace conventional radiographs as an initial imaging modality. Limited data exist on the clinical utility and cost of TCT scans in pediatric trauma. Our current practice is to obtain TCT scans in those children at risk for thoracic injures. The purpose of this study is to examine what additional information TCT provides, how frequently it results in a change in clinical management, and a cost/benefit analysis.

METHODS

Children 18 years old and younger that had both a Chest x-ray (CXR) and TCT scan in their initial workup were included. Indications for TCT scan were (1) any sign of thoracic injury on CXR, (2) pathologic findings on physical examination of the chest, and (3) high impact force to chest wall. A child may have had one or more indications for a TCT scan.

RESULTS

Between 1996 and 2000, 45 of 1,638 trauma patients met study criteria. Indications for TCT included thoracic injury on CXR (n = 27), findings on physical examination (n = 8) and high-impact force (n = 33). In 18 of the 45 (40%), injuries were detected with TCT imaging but not on CXR. These included contusions (n = 12), hemothorax (n = 6), pneumothorax (n = 5), widened mediastinum (n = 4), rib fractures (n = 2), diaphragmatic rupture (n = 1), and aortic injury (n = 1). In 8 patients (17.7%) TCT imaging resulted in a change in clinical management. These included insertion of a chest tube (n = 5) aortography (n = 2) and operation (n = 1). Age, sex, injury severity score, mechanism, and indication for TCT could not predict differences between TCT and CXR (P >.05). In our institution, the cost of a TCT is $200, and the patient charge is $906 ($94 per CXR). Based on our study data 200 TCTs would need to be done for each clinically significant change, increasing patient ($180,000) and hospital ($39,600) costs.

CONCLUSIONS

Helical TCT is a highly sensitive imaging modality for the thoracic cavity; however, routine CXR still provides clinically valuable information for the initial trauma evaluation at minimal cost. TCT should be reserved for selected cases and not as a primary imaging tool.

Analysis of chest injuries sustained during the 1999 Marmara earthquake

PURPOSE

The chest injury pattern after a major earthquake is not well understood because data on the type of trauma and surgical intervention are limited. This study was conducted to analyze patients who sustained chest injury during the Marmara earthquake that struck Turkey on August 17, 1999 registering 7.4 on the Richter scale.

METHODS

The medical reports of 528 patients transported to a military hospital in the first 48 h after the earthquake were reviewed. Two chest surgeons examined these 528 patients, 19 of whom (4%) had suffered a major chest injury. We retrospectively evaluated the injury pattern, Abbreviated Injury Score (AIS), and Injury Severity Score (ISS) in these 19 patients.

RESULTS

Eight patients (42%) had isolated chest injuries and 11 (58%) had suffered injury to more than one organ system, including chest trauma. The mean AIS and ISS were assigned as 2.9 (SD: 1) and 22 (SD: 7), respectively. Three (16%) of the 19 patients died, all of whom had suffered multiple injuries. The mean ISS of these three patients was 28.7 (range 25-34). Chest injury after a major earthquake was associated with an overall mortality rate of 16%, but chest injury with multiple injuries and an ISS over 25 was associated with a mortality rate of 60%. All patients with isolated chest injuries survived.

CONCLUSION

Coexistent trauma with chest injury and an ISS over 25 were defined as poor prognostic factors for patients rescued after a major earthquake.

Influence of flail chest on outcome among patients with severe thoracic cage trauma

Flail chest is associated with a higher morbidity compared with multiple rib fractures, and it requires early intubation. This was a prospective comparative uncontrolled study at an academic level 1 trauma center. Twenty-two patients with flail chest (FLAIL) were compared with 90 patients with more than two rib fractures but no flail chest (RIBS) to determine differences in outcomes such as mortality, significant respiratory complications (pneumonia and adult respiratory distress syndrome), need for mechanical ventilation, and length of hospital stay. Stepwise logistic regression identified independent risk factors of poor outcome. Despite similar age and rates of lung contusion and extrathoracic injury, FLAIL patients had a higher need for mechanical ventilation (86% versus 42%, P < 0.01), higher incidence of significant respiratory complications (64% versus 26%, P < 0.01), and longer hospital stay (28 +/- 21 versus 17 +/- 19 days, P = 0.04) compared with RIBS patients. Flail chest and extrathoracic injuries were independent risk factors of significant respiratory complications. Of 11 FLAIL patients who were not intubated on arrival, eight required intubation within the next 24 hours, often while receiving diagnostic studies in poorly monitored hospital areas; two of these patients suffered morbidity directly related to the delay in intubation. Three patients without associated injuries were managed successfully without intubation. Flail chest is an independent marker of poor outcome among patients with thoracic cage trauma. The majority of patients with flail chest need mechanical ventilatory support and develop significant respiratory complications. In the presence of associated injuries, intubation is unavoidable and should be done under controlled conditions early after arrival to avoid morbidity related to sudden respiratory decompensation.

[Objective evaluation of thoracic injuries and associated injuries using the Abbreviated Injury Scale and the New Injury Severity Score]

The authors focused attention on objectivization of the severity of chest injuries and associated injuries using the Abbreviated Injury Scale (AIS) and the New Injury Severity Score (NISS). They evaluated injuries detected on post-mortem examination in subjects who died from the sequelae of injuries in the Faculty Hospital Prague 10. The group comprised a total of 90 subjects regardless of sex aged 17-94 years who died in the hospital in 1996-2000. Traffic injuries accounted for 70% deaths, other blunt injuries for 27.8% and only 2.2% were penetrating injuries of the chest. The mean AIS value of the chest was 3.7, the mean value of NISS was 50.7. The NISS value declined in relation to age of the deceased patients and the period of survival. The period of survival varied from 30 mins. to 136 days. The mean NISS value on survival up to 5 hours after injury was 55.0. On comparison of our group we found that the results were consistent with those of American studies.

Clinical retrospective and comparative study on diaphragm injuries in 46 cases

OBJECTIVE

To explore a way of guiding diagnosis and treatment of blunt and penetrating diaphragm injuries.

METHODS

According to injury violence, 46 chest trauma patients with diaphragm rupture were divided into two groups: a blunt injury group and a penetrating injury group. The injury condition and trauma scores between the two groups were compared and analyzed.

RESULTS

The incidence of blunt diaphragm injuries was lower than that of penetrating injuries (1.78% vs 8.53%, P <0.05). In the blunt injury group most patients had multiple injuries. Penetrating injuries developed more quickly than blunt injuries, and resulted in hemorrhagic shock in the early period. Trauma scores showed that there was no significant difference in the Revised Trauma Score (RTS), the Injury Severity Score (ISS) and thoracic Abbreviated Injury Scale (AIS) between the two groups (P<0.05), but the blunt injury group had lower Glasgow Coma Scale (GCS) and abdominal AIS than the penetrating group (P<0.0 5).

CONCLUSIONS

Blunt and penetrating diaphragm injuries have different clinical characteristics. So they should be dealt with differently to reduce the incidence of complication and improve prognosis.

Case report: survival of a type I transthoracic impalement

The care of a patient who became impaled on a large aluminum pipe is presented. A review of the literature reveals that most patients with a type I injury either do not survive or present with an unpredictable pattern of injury. Preoperative care requires rapid stabilization, assessment, and interventions based on the pattern of injury. Perioperative management may involve multiple surgeons performing simultaneous surgical procedures.

Correlation between crash severity, injury severity, and clinical course in car occupants with thoracic trauma: a technical and medical study

BACKGROUND

The crash mechanisms and clinical course of car occupants with thoracic injury were analyzed to determine prognostic factors and to create a basis for injury prophylaxis.

METHODS

A technical and medical investigation of car occupants with a thoracic injury (Abbreviated Injury Scale-thorax [AIS(THORAX)] > or = 1) at the scene of the crash and the primary admitting hospital was performed.

RESULTS

Between 1985 and 1998, 581 car occupants sustained a thoracic injury. Mean parameter values were as follows: AIS(THORAX), 2.5; Hannover Polytrauma Score (PTS), 21.4; Injury Severity Score (ISS), 24.2; Delta-v, 49.6 km/h (30.8 mph); and extent of passenger compartment deformation (DEF) (scale, 1--9), 4.0. In 19% (n = 112) of patients involved, the clinical course was evaluated: AIS(THORAX), 2.5; PTS, 20.0; ISS, 19.3; Delta-v, 50.1 km/h (31.1 mph); DEF, 3.9; intensive care unit time, 8.3 days; ventilation time, 5.7 days; and hospital stay, 15.3 days. In the groups with higher AIS(THORAX), ISS, PTS, and intensive care unit and ventilation time, higher Delta-v and DEF occurred. In patients with longer hospital stay, higher Delta-v, but no difference in DEF occurred.

CONCLUSION

The injury severity and the clinical course demonstrated a positive correlation with the crash severity. Therefore, our technical accident analysis allows prediction of the severity of injury and the clinical course. It may consequently serve as a tool for development of more sophisticated injury prevention strategies and may improve passive car safety.

Chest tube removal: end-inspiration or end-expiration?

BACKGROUND

Recurrent pneumothorax is the most significant complication after discontinuation of thoracostomy tubes. The primary objective of the present study was to determine which method of tube removal, at the end of inspiration or at the end of expiration, is associated with a lesser risk of developing a recurrent pneumothorax. A secondary objective was to identify potential risk factors for developing recurrence.

METHODS

A prospective study of 102 chest tubes in 69 trauma patients (1.5 tubes per patient) randomly assigned to removal at the end of inspiration (n = 52) or the end of expiration (n = 50).

RESULTS

Recurrent pneumothorax or enlargement of a small but stable pneumothorax was observed after the removal of four chest tubes in the end-inspiration group (8%) and after discontinuation of three chest tubes (6%) in the end-expiration group (p = 1.0). Of those, only two tubes in the end-inspiration group and 1 tube in the end-expiration group required repeat closed thoracostomy. Multiple factors were analyzed that did not adversely affect outcome. These included patient age, Injury Severity Score, Revised Trauma Score, mechanism of injury, hemothorax, thoracotomy, thoracostomy, previous lung disease, chest tube duration, the presence of more than one thoracostomy tube in the same hemithorax, or a small (but stable) pneumothorax at the time of tube removal.

CONCLUSIONS

Discontinuation of chest tubes at the end of inspiration or at the end of expiration has a similar rate of post-removal pneumothorax. Both methods are equally safe.

[Analysis of chest radiographs of patients with thoracic trauma is not influenced by a grid nor by the experience of the reader]

OBJECTIVE

To evaluate the interest of a grid and the experience of the interpreter to interpretate the chest radiographs (CRs) of patients with thoracic trauma, the reference is the helicoidal computed tomography (HCT).

STUDY DESIGN

Prospective observational study.

MATERIAL

CRs and HCT of 50 thorax trauma patients.

METHOD

CRs were analysed without a grid (L) and results were compared with those obtained in an anterior study with a grid (G). The interpreter were residents in anaesthesiology (DESAR; G: n = 6/L: n = 4), residents in radiology (DESR; G: n = 3/L: n = 5), senior anaesthesiologists (MAR; G: n = 5/L: n = 4), and senior radiologists (MR; G: n = 3/L: n = 5). The reference was the HCT. The lectors were compared.

RESULTS

The interpretation of the CRs was neither influenced by the experience and the specialty of the lector nor by the use of a grid. Perhaps the formation is sufficient for the anaesthesiologists to evaluate the essential lesions in the trauma patient and treat them.

Imaging in thoracic trauma: the trauma surgeon's perspective

Thoracic trauma is a common cause of significant disability and mortality. Most thoracic injury in developed countries results from motor vehicle crashes (MVC). Imaging of patients with thoracic trauma must be accurate and timely to avoid preventable death. Trauma surgeons prioritize imaging options based on the patient's hemodynamic status, associated injuries, and age. The screening test for the detection of life-threatening thoracic injury is the supine anteroposterior (AP) chest radiograph. Rib fractures are a marker for serious associated injuries, including abdominal injuries. Rib fractures are especially ominous in children and the elderly. Thoracic aortic injury is associated with high-speed mechanisms of injury and can occur in the absence of radiographic signs. Chest computed tomography (CT) can be used as a screening and diagnostic tool for suspected aortic injury. Aortography is reserved for patients with high suspicion of aortic injury or for confirmation of CT scan diagnosis.

Changing indications for thoracotomy in blunt chest trauma after the advent of videothoracoscopy

BACKGROUND

The advent of videothoracoscopy may restrict the indications for thoracotomy in blunt chest trauma.

METHODS

We retrospectively compared two groups of patients with blunt chest trauma observed in consecutive periods, before and after the advent of videothoracoscopy, 989 patients from 1989 to 1993 and 908 patients from 1994 to 1998.

RESULTS

During the first period, 38 thoracotomies were performed; but in 8 instances (21%), no major injuries were found. In the second period, 36 videothoracoscopies were performed to repair the lung (n = 5) or diaphragm (n = 5), to evacuate clots (n = 4), pericardial effusion (n = 3), and empyema (n = 2). Six procedures were converted and 11 findings were negative for lesions. Only nine intentional thoracotomies were performed, and significant lesions were found in each case.

CONCLUSION

Videothoracoscopy has reduced the number of thoracotomies performed. Thoracotomy can be limited to massive bleeding with hemodynamic instability, major air leak, radiologic evidence of mediastinal enlargement or diaphragmatic rupture, or major anterolateral flail chest.

[Inter-observer reliability in the classification of thoraco-lumbar spinal injuries]

The purpose of a fracture classification is to help the surgeon to choose an appropriate method of treatment for each and every fracture occurring in a particular anatomical region. The classification tool should not only suggest a method of treatment, it should also provide the surgeon with a reasonably precise estimation of the outcome of that treatment. But to use a classification before its workability has been proved is inappropriate and can lead to confusion and more conflicting results. Any classification system should be proved to be a workable tool before it is used in a discriminatory or predictive manner. The radiographs of fourteen fractures of the lumbar spine were used to assess the interobserver reliability of the AO classification system. The radiographs and CT scans were reviewed in twenty-two hospitals experienced with spinal trauma. The mean interobserver agreement for all fourteen cases was found to be 67% (41-91%), when only the three main types (A, B, C) were used. The corresponding kappa value of the interobserver reliability showed a coefficient of 0.33 (range, 0.30 to 0.35). The reliability decreased by increasing the categories. For some injuries the interobserver reliability was found to be over 90% and also for the recommended therapeutic procedure there was an acceptable agreement. But the decision between an posterior approach alone or an additionally anterior procedure seems to be the most important question in treatment of spinal injuries at that time.

Injuries to riders in the cross country phase of eventing: the importance of protective equipment

OBJECTIVES

To determine the distribution of injuries in the eventing discipline of equestrian sports and the effectiveness of the protective equipment worn.

METHODS

Data on all injuries sustained in the cross country phase over fixed obstacles were collected from 54 days of competition from 1992 to 1997. This involved 16,940 rides.

RESULTS

Data on a total of 193 injuries were collected, which included two deaths. This represents an injury rate of 1.1%. Head and facial injuries represented the largest group (31%), with one third of these requiring treatment in hospital. All riders were wearing protective helmets and body protectors.

CONCLUSIONS

Eventing is one of the most dangerous equestrian sports. Improved protective equipment, which is mandatory for 1999, should reduce the severity of these injuries.

[Surgical management of type III thoracic shotgun injury]

Reporting the case of a short-range severe thoracic shotgun injury the differentiated management of this trauma is discussed. Indication for operative exploration under emergency conditions is hemorrhagic shock, perforation of esophagus/stomach and pericardial tamponade. Even under a toxicological point of view there is no indication for emergency revisions.

Plastic bullet injuries in Northern Ireland: experiences during a week of civil disturbance

BACKGROUND

Plastic bullets were introduced to Northern Ireland for riot-control purposes in 1973. Their use has been controversial, with a number of fatalities. In the week beginning July 7, 1996, some 8,000 plastic bullets were fired during widespread rioting.

METHODS

Details of injuries attributed to plastic bullets were obtained retrospectively from patient notes for the period July 8 to 14, 1996, in six hospitals. A total of 172 injuries in 155 patients were recorded.

RESULTS

Nineteen percent of injuries were to the face/head/neck, 20% were to the chest or abdomen, and 61% were to the limbs. Abbreviated Injury Scale scores ranged from I to 3. Forty-two patients were admitted for hospitalization, three to intensive care units. No fatalities occurred.

CONCLUSION

Plastic bullet impact to the abdomen or above may cause life-threatening injuries. Below this site, major trauma is unlikely.

Trauma! Chest injuries

Chest trauma can range from broken ribs and knife wounds to collapsed lungs and bruised hearts. This detailed discussion of mechanism of injury, assessment findings, and treatment strategies will help you identify problems and increase your patients' chances for a quick and successful recovery.

[Bronchoscopic assessment algorithms for the practical evaluation of the rheological properties of the tracheobronchial secretion and the classification of the degree of the disordered drainage function of the tracheobronchial tree (TBT) in chest and combined trauma with chest trauma as the leading injury]

Ventilation impairment, due to ineffective elimination of the mucous-hemorrhagic content from the tracheobronchial tree (TBT), obstructs the upper airways with the ensuing ventilation reduction giving rise to atelectases and progressive alveolar block. There is evidence of transudation and exudation into the pulmonary pathways and pleural cavity. A series of 276 patients presenting closed chest trauma are subjected to fibrobronchoscopy (FBS) and follow-up study. In 92 of them bronchoscopy is performed 2 to 15 times per patient, accordingly: in 75-twice, in 10-five times and in 15-twice. One-hundred twenty-nine of the total of 276 cases under study are on mechanical ventilation. In 56 instances FBS is carried out through a tracheostomy cannula, in 73-by intubation, in 18-through the mouth, and in two--through the nose. Based on the obtained results, algorithms for assessment of the rheological properties of tracheobronchial secretion and degree of impairment of TBT drainage function during emergency FBS in closed chest injuries are worked out, having an essential practical bearing on the diagnostic and therapeutic approach to closed thoracic trauma.

The childhood air gun: serious injuries and surgical interventions

OBJECTIVE

Increasingly powerful nonpowder firearms or air guns are frequently given to children as toys. We undertook the present study to evaluate the injuries caused by these firearms, based on the concern that they are capable of inflicting serious trauma.

DESIGN

Descriptive, retrospective chart review.

SETTING

Urban level I pediatric trauma center.

PARTICIPANTS

The study included all children with injuries secondary to air guns who were admitted between July 1988 and March 1995.

MAIN OUTCOME MEASURES

Type of weapon, circumstances of injury, anatomic location of injury, injury severity, surgeries performed, morbidity.

INTERVENTIONS

None.

RESULTS

There were 42 admissions with a mean hospital stay of seven days (range 1 to 136 days). The average age was 10 years (range 1 to 23 years) with a median age of 11 years. There were 35 boys and 7 girls. Twenty-nine of the 42 injuries were caused by a family member or friend and five were self-inflicted. The mean injury severity score was 8.3. While there were no fatalities, 21 children (50%) underwent operative procedures for their injuries. Ten of the injuries were potentially lethal, of which seven were due to the "pump" action air gun. Sixteen patients had serious long-term disability as a result of their injuries.

CONCLUSION

Air guns can cause a variety of serious injuries, often requiring operative intervention. The long-term morbidity from some of these injuries is significant. Both parents and physicians should be aware that nonpowder guns are not toys, but weapons capable of inflicting serious trauma. The evaluation and treatment of air gun injuries should be similar to that currently used for powder weapon injuries. Recommendations for evaluation and treatment are made.

Noncorrelation between thoracic skeletal injuries and acute traumatic aortic tear

It is generally accepted that the presence of thoracic skeletal injuries has a predictive value for acute traumatic aortic tear (ATAT). The purpose of this study is to objectively assess the validity of that premise. The initial chest radiographs of 548 patients who underwent aortic angiography for suspected ATAT were reviewed for thoracic skeletal injuries. The incidence of thoracic skeletal injuries was compared between patients with and without angiographically confirmed ATAT. Rib fracture is the only thoracic skeletal injury whose incidence is statistically significantly higher in patients with ATAT (36 of 62, 58.1%) than in those without (207 of 486, 42.6%) (p = 0.0209). The positive predictive value of rib fractures in evaluating ATAT, however, is 14.8%, a rate similar to the incidence of ATAT at most trauma centers, and the specificity is 57.4%. The second most common finding in patients with ATAT, the absence of thoracic skeletal injury, is not statistically significantly different between patients with ATAT (24 of 62, 38.7%) and those without (220 of 486, 45.3%) (p = 0.3279). We conclude that (1) there is no clinically relevant correlation between thoracic skeletal injuries and ATAT, and (2) selection of patients requiring thoracic aortography must be based on appropriate mechanism of injury and radiographic evidence of mediastinal hematoma.

Value of thoracic computed tomography in the first assessment of severely injured patients with blunt chest trauma: results of a prospective study

OBJECTIVE

The aim of this prospective study was to evaluate whether early thoracic computed tomography (TCT) is superior to routine chest x-ray (CXR) in the diagnostic work-up of blunt thoracic trauma and whether the additional information influences subsequent therapeutic decisions on the early management of severely injured patients.

PATIENTS AND METHODS

In a prospective study of 103 consecutive patients with clinical or radiologic signs of chest trauma (94 multiple injured patients with chest trauma, nine patients with isolated chest trauma), an average Injury Severity Score of 30 and an average Abbreviated Injury Scale thorax score of 3, initial CXR and TCT were compared after initial assessment in our emergency department of a Level I trauma center.

RESULTS

In 67 patients (65%) TCT detected major chest trauma complications that have been missed on CXR (lung contusion (n = 33), pneumothorax (n = 27), residual pneumothorax after chest tube placement (n = 7), hemothorax (n = 21), displaced chest tube (n = 5), diaphragmatic rupture (n = 2), myocardial rupture (n = 1)). In 11 patients only minor additional pathologic findings (dystelectasis, small pleural effusion) were visualized on TCT, and in 14 patients CXR and TCT showed the same pathologic results. Eleven patients underwent both CXR and TCT without pathologic fundings. The TCT scan was significantly more effective than routine CXR in detecting lung contusions (p < 0.001), pneumothorax (p < 0.005), and hemothorax (p < 0.05). In 42 patients (41%) the additional TCT findings resulted in a change of therapy: chest tube placement, chest tube correction of pneumothoraces or large hemothoraces (n = 31), change in mode of ventilation and respiratory care (n = 14), influence on the management of fracture stabilization (n = 12), laparotomy in cases of diaphragmatic lacerations (n = 2), bronchoscopy for atelectasis (n = 2), exclusion of aortic rupture (n = 2), endotracheal intubation (n = 1), and pericardiocentesis (n = 1). To evaluate the efficacy of all those therapeutic changes after TCT the rates of respiratory failure, adult respiratory distress syndrome, and mortality in the subgroup of patients with Abbreviated Injury Scale thorax score of > 2 were compared with a historical control group, consisting of 84 patients with multiple trauma and with blunt chest trauma Abbreviated Injury Scale thorax score of > 2, prospectively studied between 1986 and 1992. Age (38 vs. 39 years), average Injury Severity Score (33 vs. 38), and the rate of respiratory failure (36 vs. 56%) were not statistically different between the two groups, but the rates of adult respiratory distress syndrome (8 vs. 20%; p < 0.05) and mortality (10 vs. 21%; p < 0.05) were significantly reduced in the TCT group.

CONCLUSIONS

TCT is highly sensitive in detecting thoracic injuries after blunt chest trauma and is superior to routine CXR in visualzing lung contusions, pneumothorax, and hemothorax. Early TCT influences therapeutic management in a significant number of patients. We therefore recommend TCT in the initial diagnostic work-up of patients with multiple injuries and with suspected chest trauma because early and exact diagnosis of all thoracic injuries along with sufficient therapeutic consequences may reduce complications and improve outcome of severely injured patients with blunt chest trauma.