The role of a multidisciplinary team in chest wall trauma management

Abstract

Trauma represents the leading cause of death in patients younger than 45 years old. The introduction of multidisciplinary trauma teams has resulted in an improvement in patients` outcome. The thoracic surgeon plays an invaluable role as a member of the multidisciplinary team that includes an emergency physician, surgical figure, an anaesthetist, a radiology technician plus a number of nurses. Thorough knowledge of the physiological mechanism of injury and an intensive training have contributed massively in improving the outcomes. Different surgical approaches have to be considered in order to provide the best outcome to the acute patient with chest injury.

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© Journal of Visualized Surgery. All rights reserved. J Vis Surg 2019 | http://dx.doi.org/10.21037/jovs.2019.12.01
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Introduction
Despite substantial advances in trauma care over the last
few decades, trauma still represents the leading cause of
death in patients younger than 45 years old (1-3). Failure
in providing sufcient specialized care in the early phase of
major trauma led to the development of a modern model
of civilian trauma system with the Emergency Medical
System Act Public Law 93-155 issued by the United States
Congress in 1973 (4). One of the major results from this
law was the introduction of multidisciplinary trauma teams
with the purpose to stabilize the patient and reduce the time
span between the diagnosis and the treatment, with the
only goal to improve overall survival. Several studies (5-8)
have concluded that the inclusion of different specialties is
essential to reduce mortality.
As effectively described by Ludwig et al. (9) management
of chest trauma is based on three distinct levels of care
ranging from prehospital trauma support, hospital trauma
life support and surgical trauma life support. During
the primary assessment of the trauma patient as per the
Advanced Trauma Life Support (ATLS) (protocol, life-
threatening injuries should be excluded or managed. These
include airway obstruction, pneumothorax, haemothorax,
ail chest and cardiac tamponade. Subsequently, potentially
life-threatening injuries should be dealt with or ruled
out, including pulmonary and myocardial contusion,
diaphragmatic injury and disruption of the tracheobronchial
tree, oesophagus and aorta.
The thoracic surgeon plays an invaluable role as a
member of an extended, multidisciplinary team, whose
main goal is to reduce morbidity and mortality secondary
to trauma. A good knowledge and profound understanding
of the underlying pathophysiologic mechanisms associated
with thoracic trauma is necessary to guide the management
of this challenging clinical entity.
The role of a multidisciplinary team in chest wall trauma management
Davide Patrini1, David Lawrence1, Savvas Lampridis1, Fabrizio Minervini2, Lorenzo Giorgi3,
Roberto Palermo3, Martin Hayward1, Marco Scarci4, Joachim Schmidt5, Benedetta Bedetti5
1Department of Thoracic Surgery, University College London Hospitals, London, UK; 2Department of Thoracic Surgery, Cantonal Hospital
Lucerne, Lucerne, Switzerland; 3Department of Thoracic Surgery, University of L’Aquila, L’Aquila, Italy; 4Department of Thoracic Surgery, San
Gerardo Hospital, Monza, Italy; 5Department of Thoracic Surgery, Malteser Hospital, Bonn, Germany
Contributions: (I) Conception and design: D Patrini, B Bedetti; (II) Administrative support: M Scarci; (III) Provision of study materials or patients:
M Hayward, J Schmidt; (IV) Collection and assembly of data: L Giorgi, R Palermo; (V) Data analysis and interpretation: D Patrini, B Bedetti, S
Lampridis; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.
Correspondence to: Mr. Davide Patrini. Consultant Thoracic Surgeon, Thoracic Surgery Department, University College London Hospitals, 16-18
Westmoreland St. W1G 8PH, London, UK. Email: davide.patrini@nhs.net.
Abstract: Trauma represents the leading cause of death in patients younger than 45 years old. The
introduction of multidisciplinary trauma teams has resulted in an improvement in patients` outcome.
The thoracic surgeon plays an invaluable role as a member of the multidisciplinary team that includes
an emergency physician, surgical figure, an anaesthetist, a radiology technician plus a number of nurses.
Thorough knowledge of the physiological mechanism of injury and an intensive training have contributed
massively in improving the outcomes. Different surgical approaches have to be considered in order to
provide the best outcome to the acute patient with chest injury.
Keywords: Thoracic surgery; chest wall trauma; multidisciplinary team
Received: 11 November 2019. Accepted: 29 November 2019.
doi: 10.21037/jovs.2019.12.01
View this article at: http://dx.doi.org/10.21037/jovs.2019.12.01
Review Article

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© Journal of Visualized Surgery. All rights reserved. J Vis Surg 2019 | http://dx.doi.org/10.21037/jovs.2019.12.01
The concept and composition of the trauma
team
A team spirit is mandatory for appropriate delegation of
tasks among members involved in the assessment and
management of the trauma patient. In this context, a
horizontal distribution of tasks has been proven to be
effective in improving clinical outcomes (10). Regarding the
composition of the trauma team, variations exist between
different countries and healthcare system (11,12); however,
several factors are often common. In a basic set up, the
trauma team is often led by a surgeon who coordinates
according to the ATLS guidelines; his role can also be
taken by an emergency physician. The rest of the team is
composed by an anaesthetist, a radiology technician and
a variable number of nurses. Airway management, which
takes priority over all the other tasks, is usually carried
out by the anaesthetist. His tasks also include intubation,
ventilation and airway-associated interventions. The
surgeon is responsible for the coordination of the trauma
team, the primary survey of the patient and potential
operative procedures. The radiology technician performs
imaging investigations and may assist the surgeon in
their interpretation. A radiologist will be required if a
formal report is needed and in case the patient undergoes
computed tomography (CT). Finally, the nursing staff make
the alert calls, record vital information, take blood samples,
place monitoring devices, set up the ventilator and assists
the anaesthetist and the surgeon. It is worth noting that
in some hospitals a neurologist or a neurosurgeon is often
involved to assess more accurately the Glasgow Coma Scale
score, focal neurological decit and pupillary light response.
Prehospital management
Patient assessment with clinical examination including,
inspection, palpation, percussion and auscultation are
essential to recognize major thoracic injuries, such as open
and tension pneumothorax, hemothorax, flail chest and
lung contusion. Tension pneumothorax is the most frequent
reversible cause of cardiac arrest (12). Therefore, rapid
and accurate assessment for diminished chest expansion
and absence of breath sounds on the ipsilateral side can
be lifesaving. Needle decompression is the first line of
treatment followed by insertion of a chest drain.
Diagnostic imaging
Patients with thoracic trauma are at high risk for both
intrathoracic and intraabdominal injuries, depending on the
mechanism and energy of the injury. Thorough assessment
with various imaging modalities is advised in all but few
cases, in which clinical suspicion is high and any delay
in treatment may prove catastrophic. Imaging typically
includes extended focused assessment with sonography
in trauma (eFAST) for rapid detection of hemothorax,
hemopericardium, pneumothorax and intraperitoneal
bleeding (13,14). More advanced imaging investigations
include CT of the chest, which provides more detailed
information. A CT is characterised by greater sensitivity
and specificity compared to a plain chest radiograph,
although the latter is generally sufcient to detect clinically
significant injuries. However, a CT should be avoided in
hemodynamically unstable patients. In these cases, the
importance of eFAST to rule out life threatening injuries
cannot be underestimated.
Emergency room management
A full assessment of the patient should be performed by
the trauma team in the emergency room according to a
predefined algorithm. Thorough and repeated clinical
examination, review of the mechanism of thoracic injury
and information about the past medical history of the
patient are considered invaluable tools for successful
management. According to the ATLS guidelines (15), a
thoracic surgeon should be involved in case of persistent
blood loss after chest drain insertion (1,500 mL acutely or
more than 200 mL per hour for 3–4 consecutive hours),
severe subcutaneous emphysema, massive haemoptysis,
penetrating chest trauma and substantial air leak from
a chest tube. Immediate surgery is advised in case of
persistent intrathoracic bleeding, endobronchial blood loss
with ventilation impairment, penetrating injury and flail
chest.
Surgical management
In order to access the chest in an emergency setting,
anterolateral thoracotomy is the access of choice permitting
good exposure of thoracic organs. Differently from the

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classic posterolateral thoracotomy a more anterior approach
will avoid the rotation of the patient on a side. In 20% pf
patients the thoracotomy may be insufficient to visualize
all the lesions therefore alternative approach such as
Clamshell (transverse sternotomy and bilateral anterolateral
thoracotomy) may be required (16).
In the management of chest trauma there is also a role
for minimally invasive surgery: indications for video assisted
thoracoscopic surgery (VATS) may include (I) penetrating
injury with minimal blood loss on a stable patient; (II)
hemothorax; (III) empyema; (IV) persistent air leak; (V)
concerns about diaphragmatic involvement.
VATS has shown its value in the management of
pleural space involvement in the non-critical stable
patient (17). Thoracoscopic assessment of the pleural cavity
can demonstrate misdiagnosed injuries and lesion and
treat a potential persisting hemothorax (18). Jin et al. (19)
highlighted an advantage of VATS over open thoracotomy
approach in a randomized trial demonstrating a lower rate
of ARDS rates comparing to open thoracotomy patients.
The benefits of VATS are evident as long as strict
inclusion criteria are respected: in a hemodynamically
unstable patient with severe chest or cardiac vessel injury
an open approach must be the preferred choice leaving
no place for thoracoscopic surgery that can only have a
negative impact on outcomes by delaying the unavoidable
conversion to open thoracotomy (20).
The effect of the trauma team on clinical
outcome
The aim of the trauma team is to reduce morbidity and
mortality and thus improve patient outcome. Indeed, since
the introduction of the trauma team worldwide, there
is strong evidence to support that patient outcome has
improved significantly (21). This improvement is noted
not only in the improved management of moderately
and severely injured patients, but also in the higher rate
of unexpected survivors due to the efficient role of the
trauma team. Contrariwise, patients who meet the criteria
for trauma call and are not treated by a trauma team,
demonstrate higher rates of morbidity and mortality (22).
Trauma team training
Advance trauma life support course (ATLS)
The first ATLS course was held in USA in 1978. It
was originally developed for doctors in rural areas and
subsequently expanded by the American College of
Surgeons in 1980. The ATLS course is now widely accepted
and has resulted in better patient outcomes in several
studies (23).
Simulators
Simulation-based training creates a situation where
certain skills are applied as in a real-world environment.
Skill development is achieved through repetition and
constructive feedback (24). There are several modalities of
simulation-based training, which all share the same goal: to
enable the trainee to acquire a wide set of skills. There is no
consensus whether using a standardized manikin or a patient
will make a difference when considering communication,
cooperation and leadership skills (25). A study by Wisborg
and colleagues (26) confirmed this observation, although
considering that the outcome is measured in participant’s
assessment of their role and the degree of realism rather
than with a more objective outcome score.
Videotaping
Several studies have been published on the benefits of
recording simulated or actual trauma situations (27-29). The
benets of this are threefold: rstly, recorded video can be
used for educational purposes, by creating opportunities to
review and modify behaviour in a controlled environment;
secondly, it can be used to assess and measure the adherence
to the ATLS protocol; lastly, recorded video can be used
also for research purposes (30).
Conclusions
Leadership and communication skills are considered of
paramount importance in the effective management of
a trauma team. Moreover, appropriate supervision and
support by the senior members, as well as self-awareness
and ability to seek help by the junior members, are
warranted to improve the efcacy of the team. Furthermore,
thorough knowledge of the role of each member and clearly
dened tasks may have a signicant impact on the clinical
outcome of trauma patients. Management of these patients
should follow general principles of well-established trauma
protocols and, depending on the pathophysiology of each
individual case, it can range from simple observation to
salvage surgery (Figure 1).

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© Journal of Visualized Surgery. All rights reserved. J Vis Surg 2019 | http://dx.doi.org/10.21037/jovs.2019.12.01
Acknowledgments
None.
Footnote
Conicts of Interest: The authors have no conicts of interest
to declare.
Ethical Statement: The authors are accountable for all
aspects of the work in ensuring that questions related
to the accuracy or integrity of any part of the work are
appropriately investigated and resolved.
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Video 1. Learning points in chest wall
trauma management
Davide Patrini*, David Lawrence, Savvas
Lampridis, et al.
Department of Thoracic Surgery, University
College London Hospitals, London, UK
Figure 1 Learning points in chest wall trauma management (31).
Available online: http://www.asvide.com/

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doi: 10.21037/jovs.2019.12.01
Cite this article as: Patrini D, Lawrence D, Lampridis S,
Minervini F, Giorgi L, Palermo R, Hayward M, Scarci M,
Schmidt J, Bedetti B. The role of a multidisciplinary team in
chest wall trauma management. J Vis Surg 2019.