Which of the following statement(s) is/are true concerning the management of chest trauma?

d. Persistent bleeding associated with a penetrating injury to the chest is often due to injury to an artery of the systemic circulation

The chest radiograph is by far the most important diagnostic study in patients with chest trauma and should be obtained early in all patients. Angiography is the best study to rule out major injury to the great vessels in the chest, and angiography remains mandatory in the majority of patients at risk for aortic disruption who have an abnormal chest radiograph. At the present time, CT scan of the chest appears to have a higher rate of missed injury than angiography for assessment of the aorta and should probably be avoided in patients with abnormal chest films. The majority of injuries to the chest can be successfully managed without surgical intervention. The routine use of a tube thoracostomy for treatment of hemothorax and pneumothorax is the cornerstone of therapy. Thoracotomy is most often needed for the control of massive bleeding, or bleeding which persists despite tube thoracostomy. About 80% to 85% of hemorrhages within the chest can be treated by tube thoracotomy alone. Even larger and deep lacerations of the lung parenchyma, which bleed with relatively low pressure from the pulmonary circulation, will be controlled by the reinflated lung parenchyma as well as edema in the tissue from the injury. Persistent bleeding is most commonly due to injuries to major proximal branches of the pulmonary circulation or injuries to systemic arteries including intercostal arteries and internal mammary arteries. The choice of position and surgical approach for thoracotomy for thoracic injury is dictated by the nature of the patient’s injuries, the certainty of diagnosis, and the potential for associated injuries involving other body sites. Although the standard postero-lateral thoracotomy provides optimal exposure to the contents of a particular hemithorax, the lateral position of the patient makes access to the other side of the chest or abdomen difficult if not impossible. Therefore, though postero-lateral thoracotomy provides the best access, it can be used only in patients who have injuries isolated to a given hemithorax. In most patients undergoing emergency thoracotomy for chest trauma, an antero-lateral approach must be used in patients supine to allow access to the abdomen and contralateral chest cavity. Although exposure through this incision is considerably more difficult, it is adequate with proper technique. Median sternotomy incision provides excellent exposure to the heart and the great vessels in the anterior mediastinum, but it provides very difficult exposure for repair of injuries to the lungs, descending aorta, chest wall, diaphragm, or esophagus. Therefore, like the postero-lateral thoracotomy, it can be used only when the patient’s injuries can be determined with relative certainty.