Category Archives: Thorax

Survival After Penetrating Injury To The Heart

June 23, 2026 The Trauma Pro

Penetrating injury to the chest, and especially the heart, has a high mortality rate. The best way to reduce mortality is rapid pre-hospital transport to a trauma center where life-saving measures can be carried out immediately. Frequently, these measures include resuscitative thoracotomy. The Western Trauma Society has a well-known guideline to help with decision-making in performing this procedure.

The trauma group at Sinai Chicago recently published a paper slicing and dicing the possible predictors of survival after cardiac injury. As I read this paper, I was curious about how this information would change our practice, especially with the decision to open the chest.

The authors performed a retrospective cohort study of patients who had suffered penetrating cardiac trauma over nine years. Here are the factoids:

Over 18,000 patient encounters were analyzed (average 2,000 per year), and only 57 penetrating cardiac injuries were identified (3%)
Overall survival was 25% (!)
Gunshot victims were 3.7x more likely to die
Mortality odds ratios for specific injury patterns were as follows:
- Multiple cardiac chambers injured 11x
- Thoracic vascular injury 12x
- Concurrent abdominal injury 4.4x
These findings were noted to decrease the likelihood (odds ratio) of death:
- Isolated cardiac injury 0.2x
- Spontaneous respirations 0.06x
- Signs of life on arrival 0.01x
Every patient (35) who underwent resuscitative thoracotomy died

The authors suggested that recognizing these factors could help clinicians in decision-making processes during early triage and resuscitation.

Bottom line: When I first read the paper, it seemed that this was all common-sense information and didn’t add much to our body of knowledge. However, upon closer reading, there are some good tidbits here. The work here helps identify which patients are most likely to benefit from opening the chest. It assigns probabilities to anatomic and physiologic criteria, some of which are apparent at the time of patient arrival and are available for decision making. The fact that every patient who underwent resuscitative thoracotomy died is not alarming; it merely reflects the fact that these are patients who are the sickest of the sick.

So how do we put the information in this paper to use? The resuscitative thoracotomy algorithm from the Western Trauma Association should be utilized first. When the patient is on the cusp of the 15-minute CPR decision point, the odds ratios in this paper might be used to tilt the scales one way or the other. Does the patient also have abdominal injuries? Are there no signs of life? Then perhaps clinician judgment may dictate that the procedure not be performed. Alternatively, if the thoracotomy is carried out in patients and any of the three high-risk anatomic indicators for death are present, they might then choose to terminate the procedure to conserve resources.

Overall, this paper does not force any major changes in care. It informs the trauma professional and allows them to couple that information with existing algorithms and care processes, so they might either further improve the patient’s probability of survival or conserve scarce resources if survival is unlikely.

References:

Predictors of survival after penetrating cardiac trauma: injury patterns and presentation factors. Trauma Surg Acute Care
Open 2026;11:e002237.
Western Trauma Association Resuscitative Thoracotomy Practice Guideline

Technique, Thorax

How Good Is The Erector Spinae Plane Block?

May 26, 2026 The Trauma Pro

In my last post, I shared a video outlining the technique for providing an erector spinae plane block (ESPB). Today, I’ll review the most recent analysis of this procedure’s efficacy and safety.

As outlined previously, the ESPB targets the plane between the fascial layers of the thorax, providing analgesia in patients with rib fractures. The technique for use in trauma is relatively new, was first described in 2016, and studies on its effectiveness are finally beginning to accumulate. The most recent and comprehensive was recently published in the Clinical Journal of Pain by a group from Taiwan.

The authors performed a comprehensive search of papers published through 2025. They included only prospective studies comparing pain relief from fascial plane blocks (both ESPB and serratus anterior plane block (SAPB)) with epidural analgesia or no block. They identified only nine papers that included 600 patients, but only 5 used ESPB.

Here are the factoids:

Overall, fascial plane blocks in general (both SAPB and ESPB) significantly improved subjective pain scores during the first six hours, but were not after that for patients not receiving an epidural
When looking at SAPB alone, pain scores were improved during the first 24 hours; with ESPB alone, they were only improved during the first 6 hours.
Both types of plane blocks achieved pain scores similar to epidural analgesia
Both blocks decreased in-hospital opioid use, but this was not statistically significant
Hypotension occurred significantly less with fascial plane blocks compared to epidural analgesia
There was no difference in hospital length of stay with plane blocks compared to standard treatment

Bottom line: What does it all mean? First, there is still too little data to distinguish nuances in outcomes when comparing ESPBs and SAPBs. However, it appears that plane blocks result in less hypotension and so are a bit safer. However, subjective pain scores are only improved during the first 6 hours with ESPB. This suggests that there may be a significant placebo effect for this invasive procedure. Opioid use is the same.

With the exception of the first six hours, ESPB doesn’t look that exciting. It requires special equipment (ultrasound) and a trained provider to perform. It works as well as an epidural, which makes it more useful in patients with contraindications to this modality.

My take is that this may be a promising technique, but it’s still a bit too early to tell. This “large” series included only 600 patients, and fewer than half had the ESPB. So keep studying this procedure to see if it makes sense in the future.

Reference: Efficacy and Safety of Serratus Anterior Plane Block and Erector Spinae Plane Block for Rib Fracture Pain: A Systematic Review and Meta-analysis. The Clinical Journal of Pain 42(2):e1334, February 2026. | DOI: 10.1097/AJP.0000000000001334

Technique, Thorax

What Is It: The Erector Spinae Plane Block

May 20, 2026 The Trauma Pro

Chest trauma is extremely common, and the incidence is rapidly increasing in the elderly population, with the rapid increase in falls. Rib fractures are always a concern, and the most important factor in their management is pain control.

Over the years, numerous modalities have been described, including:

Decreasing rib motion using taping or rib belts (highly discouraged due to the incidence of complications)
Systemic pain medication (may cause respiratory depression)
Epidural analgesia (contraindicated in patients on anticoagulants)
Intercostal nerve (rib) blocks (not all ribs accessible)
Intrapleural analgesia (not very effective, with unpredictable absorption and spread)
Rib fixation procedures
Erector spinae plane blocks

In general, we have been moving from more general to very focused pain control. Analgesic usage has predominated, with operative procedures recently becoming more common for select patients.

The new kid on the block now is the erector spinae plane block (ESPB). It is technically easier to provide relief for rib fractures at most levels. It involves small injections and is relatively simple to perform under ultrasound guidance after proper training.

This video is a good introduction to the general concepts and techniques for the ESPB. Obviously, watching a video will not give you the skills to do this yourself. Work with a trained professional to gain experience with this technique.

In my next post, I’ll review the data on the efficacy and value of this block.

Thorax

Can I Keep Patients With More Than Three Rib Fractures At My Level IV Trauma Center?

April 18, 2025 The Trauma Pro Leave a comment

Rib fractures are one of the most common thoracic injuries presenting to trauma centers. Traditionally, many state designation standards set limits on the number of rib fractures in patients to be admitted to Level IV trauma centers. The assumption was that these centers had limited surgical capabilities and might not have the expertise to manage them to achieve optimal patient outcomes. They were then forced to transfer these patients upstream to a higher-level trauma center.

And then, unfortunately, COVID came along, and things changed. Mainly for the worse. Due to reduced professional staffing throughout the entire continuum of health care, the upstream centers are saturated and have limited availability to absorb patients who don’t take advantage of their increased resources.

Both staffing and reimbursement issues strain rural EMS agencies. It is difficult to justify transferring a patient to a center that takes the only ambulance in the community out of service for a good portion of the day. Also, most current state trauma system standards do not fully appreciate non-surgeon clinicians’ interest and skill levels at those Level IV centers.

The Pennsylvania Trauma Systems Foundation recognized these issues at the centers in its state. In 2020, it opted to liberalize the number of rib fractures that could be treated at Level IV centers. It required hospitalists to be current in ATLS in order to admit these patients. The centers were also required to adhere to a chest injury guideline created for them.

To gauge the safety and effectiveness of this change, a retrospective state registry study was performed comparing patients admitted during the 2.5 years before the standards change to the 2.5 years after. Demographics, injury characteristics, length of stay, and mortality were compared between the groups. Patients were excluded if they had significant injuries in other body regions, were age < 18 years of age, or had complicated fractures (requiring supplemental oxygen on admission, concomitant pneumothorax or hemothorax, pulmonary contusion or laceration, or who did not require admission

Here are the factoids:

Over 4,000 patients were recorded in the registry during the 5 years, but 3350 were excluded due to the definition of complex rib fractures
A final total of 1,070 patients were included, with 710 admitted to Level III centers and 360 to Level IV centers
This left 132 Level III patients and 228 Level IV patients in the pre- and post-standard groups, respectively
The number of transfers out of the Level IV centers dropped significantly, from 56% to 21%
Patients with <3 rib fractures had the same length of stay as those with more than three (3 vs 2, respectively)
Mortality was extremely low and not significantly different based on the number of rib fractures

Bottom line: This study showed that the change in admission standards for rib fractures in Pennsylvania did not impact outcomes and resulted in significantly fewer transfers.

The key to a successful change like this involves education and protocols. The requirement that hospitalists be current in ATLS is beneficial because it gives them a better understanding of the physiologic effects and priorities in managing trauma patients. A well-designed practice guideline is critical so that all clinicians apply best practices in caring for these patients.

This is an important paper, and should be considered in any state where local resources are being challenged, and hospital reimbursements are declining. This type of standards change may breathe new life into many of our Level IV centers.

Thorax

Chest Tube Size: The Argument That Never Dies

October 11, 2024 The Trauma Pro Leave a comment

I’ve written many posts in the past about the arguments surrounding chest tube size: large bore vs. small bore (pigtail). For the longest time, only a few decent papers were looking into this debate, and subject numbers were small. The best the papers could say was that “small-bore chest tubes are not inferior to large-bore tubes.” Not that this is not the same as saying, “small-bore tubes are better than large-bore tubes.”

But finally, after more than ten years, there has been enough written on the topic that a pass at a systematic review and meta-analysis has been attempted. The University of Miami Ryder Trauma Center group performed a comprehensive review of the topic, spanning literature published through 2022.

Here are the factoids:

A total of 2008 articles were identified, but after careful screening, only 11 articles met predetermined parameters for inclusion
There were 3 randomized, controlled studies, 3 prospective cohort studies, and 5 retrospective cohort studies
Two pairs of studies had overlapping patients, so only patients in the more recent study of each was included
The authors used CASP scoring to judge the quality and likelihood of bias. Nearly all studies included were of high quality.

And here are the interesting findings:

There was no significant difference in failure rates between small and large tubes (18% vs. 22% )
There were no differences in complication rates (12% vs. 13% )
There was a significantly higher amount of initial drainage with the small tubes (750 cc vs 400 cc) (??)
Although the overall number of complications was the same, there were significantly more insertion complications in the small-bore group (4.4 vs 2.2). These included intra-hepatic placement, malpositioned tubes, kinked tubes, and dislodgement.
Only one study used a validated pain score to measure insertion pain, and there was no difference between the tube sizes
Tube days averaged 1.5 days less in the small-bore group, which was significant. However, this did not impact ICU or hospital length of stay.

Bottom line: There are still significant limitations in this study due to the small number of randomized controlled trials that are yet available. I also worry that there is some selection bias in many of the studies that would cause large-bore tubes to be inserted preferentially into patients with more severe chest trauma, larger hemothorax, or more emergent need for the tube. However, if there were major, major differences, they would probably be starting to rear their heads by now.

The authors of this paper concluded that “small bore tube thoracostomy may be as effective as large bore thoracostomy for the management of patients with hemothorax.” They correctly suggest that guided studies examining which patients are more suited for a specific sized tube. I totally agree.

For now, I still don’t think there is a definitive answer. I recommend that the bedside trauma professional use their judgment regarding patient condition, the magnitude of the chest trauma, and the urgency of the procedure to select a size. They must also consider their expertise with the tube selected to maximize effectiveness and minimize complications.

I’m sure there will be even more to write on this topic. It doesn’t seem to want to die.

Reference: Small versus large-bore thoracostomy for traumatic hemothorax: A systematic review and meta-analysis. Journal of Trauma and Acute Care Surgery 97(4):p 631-638, October 2024. | DOI: 10.1097/TA.0000000000004412

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