Trauma ICU Rounds – The Deadly Dozen of Thoracic Trauma

Originally posted on Trauma ICU Rounds on April 17, 2020. Follow Trauma ICU Rounds (@traumaicurounds) and Dr. Kim (@dennisyongkim) to learn more on simplifying trauma critical care together.

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In this episode we review the “lethal 6” and “hidden 6” chest injuries that comprise the deadly dozen of thoracic trauma. Mechanism of injury together with vital signs and findings from the physical exam should provide us with the data needed to identify life-threatening thoracic injuries on our primary survey. For hidden injuries, the diagnostic adjuncts required to identify these injuries are also discussed.


Injuries of the chest are common following both blunt and penetrating trauma. >85% of these injuries may be adequately managed via chest tube thoracostomy, aka. chest tube insertion. The primary survey as outlined in Advanced Trauma Life Support (ATLS) consists of:

  • Airway with C-spine precautions

  • Breathing & Ventilation

  • Circulation with Hemorrhage control

  • Disability (GCS and pupillary exam)

  • Exposure / Environmental.

The deadly dozen of trauma can be arbitrarily divided into the lethal 6 or those injuries that may kill your patient immediately and should be identified on the primary survey and the hidden 6 or those injuries that are “hidden” from the sense and require further adjunctive diagnostic tests in order to diagnose.

Learning Objectives

#1 – Describe the initial assessment & management of the trauma patient

#2 – Apply an anatomic-based approach to identifying the 12 most common thoracic injuries

#3 – Develop an appreciation for the importance of the mechanism of injury & physical exam findings in identifying the presence of life-threatening thoracic injuries.

Take Home Points

  • Mechanism of injury together with vitals and a focused physical exam should alert you to the presence of a life-threatening thoracic injury

  • The vast majority of chest injuries can be initially and definitely managed with a well-placed chest tube

  • Hidden injuries require more than a thoughtful physical exam. Common adjuncts or modalities to identify these injuries include CXR, CT scan, EKG, and labs including CK/Tn

Time Stamps

  • 00:12 Introduction

  • 01:33 Learning Objectives

  • 02:31 Initial Assessment & Management of Trauma Patients

  • 05:13 Airway obstruction (LETHAL)

  • 05:57 Tracheobronchial & Esophageal injury (HIDDEN)

  • 07:40 Pulmonary contusions (HIDDEN)

  • 08:07 Pneumothorax

  • 08:32 Tension Pneumothorax (LETHAL)

  • 11:23 Open Pneumothorax or “sucking chest wound” (LETHAL)

  • 14:12 Massive Hemothorax (LETHAL)

  • 16:00 Cardiac Tamponade (LETHAL)

  • 18:00 Blunt Cardiac Injury (HIDDEN)

  • 18:30 Blunt Thoracic Aortic Injury (HIDDEN)

  • 19:30 Dipahragm Rupture (HIDDEN)

  • 20:55 Flail Chest (LETHAL)

  • 22:11 Summary

  • 22:41 Outro

The Lethal 6 of Thoracic Trauma

Lethal 6 Table.png

The Hidden 6 of Thoracic Trauma

Hidden 6.png

Recommended Readings

Kim DY, Coimbra R. Thoracic Damage Control. In: Di Saverio S, Tugnoli G, Catena F, Ansaloni L, Naidoo N. eds. Trauma Surgery Volume 2: Thoracic and Abdominal Trauma. Philadelphia, PA: Springer-Verlag Italia; 2014:35-45.

Singh M, Kim DY. Chapter 13 Pulmonary Trauma. In Koyfman A & Long B. eds. The Emergency Medicine Trauma Handbook. Cambridge University Press. 2020.

Yousefian O, de Virgilio C, Grigorian A, Kim DY. Stab Wound to the Chest. In de Virgilio C, Gregorian A. eds. Surgery: A Case Based Clinical ReviewSecond Edition. Springer, 2018.

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