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Operative management of pulmonary injuries: Lung-sparing and formal resections
Chest injuries were reported in the Edwin Smith Surgical Papyrus as early as 3000 bc . Ancient Greek chronicles reveal examples of penetrating chest wounds and pulmonary injuries; the Greeks had anatomic knowledge and were cognizant of the thoracic structures and the position of the lungs inside the hemithoracic cavities. In Homer’s Iliad , there is a vivid description of the death of Sarpedon by Patroclus: “[H]e penetrated him with his spear and while taking it out, his diaphragm came along with it . . .” Homer emphasized the importance of the diaphragm, anatomically related to the lungs and the “beating heart.” Although pneumothorax was a well-known entity, the Greeks realized the special problems related to thoracic penetration and considered open chest wounds fatal. Although the success of these early treatment modalities remains unknown, it seems that during Olympic competitions, physicians in ancient Greece were at least able to identify potentially lethal chest injuries and most likely attempt their treatment.
Pausanias, a Greek traveler during the height of Roman rule, described a penetrating injury to the chest, inflicted to Creugas of Epidamnus by Damoxenos of Syracuse, with the presence of what seems to be an obvious pulmonary injury. Eusebius described in Evangelical Preparation, the match of Cleomedes of Astypalaia against Ikkos of Epidauros: “Why did they deify Cleomedes? For opening his opponent’s rib, inserting his hand inside and eviscerating his lung.”
Galen (130–200 ad ), one of the most prominent physicians of antiquity, described packing of chest wounds in gladiators with thoracic and possibly lung injuries. A description of a lung injury was found in a treatise of Theodoric in 1226: “[W]hile I was living in Bolonia, a certain Domicellus, a Bolognan of normal birth was, cured by the hand of Master Hugo, part of his lung being torn away and Master Roand was there to witness it. . . .”
Even in the ancient world, most of the therapeutic modalities for chest wounds and traumatic pulmonary injuries were developed during wartime. In 1635, Alvar Nuñez Cabeza de Vaca, a Spaniard, while traveling from the Mexican northern territory to the capital of Nueva España (Mexico City), was captured by Indians. A wounded member of the tribe was brought to Cabeza de Vaca. With his assistant Esteban, Cabeza de Vaca made an incision to remove an arrowhead embedded in the man’s chest and sutured the wound. His innovation in surgical management won freedom from his captors for him and his friend.
During the 16th century, a few contributions were made to the management of traumatic pulmonary injuries. Ambroise Paré treated penetrating thoracic injuries by placing a scalding mixture of oil and treacle in the wound as the first dressing. John Hunter’s initial experience dealing with penetrating thoracic injuries, caused by smooth-bore muskets firing round lead balls, led him to recognize that projectile velocity is a determinant factor dictating severity of the injury. Jean-Dominique Larrey and Pierre-Joseph Desault made important contributions to the surgical procedure known as débridement for the management of chest wall lacerations; however, the surgical treatment of intracavitary injuries did not evolve significantly during this time. Although Larrey described operative techniques for dealing with penetrating cardiac injuries, his contributions to the management of pulmonary injuries are not remarkable.
In 1822, William Beaumont, better known for Beaumont’s gastric fistula observations than for his management of life-threatening chest injuries, treated a patient who sustained a gunshot wound to the chest and described the nature of the injury: “fracturing and carrying away the anterior half of the 6th rib, lacerating the lower portion of the left lobe of the lung, diaphragm and penetrating the stomach.” During the 18th century, controversies emerged surrounding the benefit of surgical manipulation in the treatment of traumatic thoracic and pulmonary injuries. In Germany, Auenbrugger said: “[O]pening the chest caused asphyxia because the lung collapsed.” Dupuytren, a famous French surgeon, personally developed empyema in 1835. Although prepared to undergo a surgical intervention for its treatment, he decided, based on knowledge about Auenbrugger’s description of “open-chest asphyxia,” that “he would rather die at the hands of God than of the surgeons;” he survived for 12 days.
In the 1840s, the French Academy of Medicine studied the treatment of empyema to produce guidelines for its treatment based on war experiences. In the 18th century, Hewson called attention to the mechanism of pulmonary rupture after blunt trauma to the chest, and in 1886, Ashurt described rupture of thoracic viscera without rib fractures. In 1889, Holmes, consulting surgeon to St. George’s Hospital in London, said: “All penetrating wounds to the chest, if small, should be closed at once and dressed antiseptically. If the wound is large and the lung evidently extensively injured, it is a better plan not to close the external wound completely, but to insert a large drainage tube to carry off the blood into an antiseptic dressing and so prevent its accumulation in the pleural cavity.” In 1897, Duval described median sternotomy incision, which he described as a thoracolaparotomy, and in 1906, Spangaro, an Italian surgeon, described the left anterolateral thoracotomy incision. These incisions remain important contributions to the trauma surgical armamentarium to manage traumatic pulmonary injuries.
In 1916, Mentz reported removal of foreign matter from the lung and pointed out the relative safety of thoracotomy. The treatment of thoracic wounds in World War I started with many of the basic principles described in the 19th century. Specifically, hemothoraces were treated expectantly. Hemothoraces were not aspirated in the belief that tamponade of the injured lung had occurred. However, when surgery was required for thoracic injury, it was aggressive and largely successful following principles of airtight closure for wounds and removal of foreign bodies. In contrast to their surgical counterparts in the German Army, American surgeons with the Allied Expeditionary Force used positive-pressure anesthesia and a nitrous oxide/oxygen mixture, while practicing early thoracotomies following the principles for good exposure injuries, resection of affected anatomic structures, suture ligature, and irrigation of the thoracic cavity. Thoracotomies were closed airtight, traumatic wounds excised, and no drains were placed. This technique was associated with a 9% decrease in mortality rate. During this time Grey-Turner, Miles, Gask, Duval, and Bastianelli defined the technique of pulmonary decortication for the treatment of retained hemothorax after traumatic lung injuries (White).
In World War II, because of increased awareness of the high incidence of complications associated with hemothorax after wounding, an approach of aggressive conservatism for the management of hemothorax was adopted. Thoracentesis was used repeatedly until the thoracic cavity was totally evacuated. No air was permitted to enter the thoracic cavity. The injured lung was allowed to reexpand and tamponade bleeding, in hopes of returning pulmonary function to normal levels. Water-sealed intercostal catheters were placed in patients with tension pneumothoraces. Thoracotomy was reserved for continued hemorrhage or significant air leaks; additional indications included thoracoabdominal wounds, mediastinal injuries, traumatic thoracotomy, “the sucking chest wound,” and removal of foreign bodies. Overall mortality rate with this treatment of war chest wounds was reported as 8%.
The Korean conflict created newer challenges for surgeons. Terrain characteristics and unfavorable tactical conditions, coupled with numerous incoming casualties, overloaded mobile army surgical hospitals (Mobile Army Surgical Hospital units). Conservative management of traumatic hemothorax was thus a therapeutic strategy extremely suited to these conditions. Eighty percent of casualties from the Korean War were managed by repeated thoracentesis alone; however, there was limited experience with the use of chest tubes for drainage of hemothorax. The introduction of more advanced resuscitative techniques helped to compensate somewhat for the problems encountered with forward treatment.
In the Vietnam conflict, chest tube drainage for pulmonary injuries and hemothorax was widely practiced. Casualties were evacuated early at the hospital directly from combat. Well-organized “trauma centers” with cardiothoracic surgical capabilities operated under strict resuscitative protocols. Given the success of tube thoracostomy in this setting, early thoracotomy was indicated for fewer patients with hemothorax, although the former indications for its use remained. Tube thoracostomy remains the cornerstone for the treatment of traumatic hemothorax or pneumothorax, as well as for most traumatic injuries to the lung.
Recent awareness based on civilian and military experience has led to the recognition that complex procedures, such as anatomic resections and pneumonectomy in unstable patients, are poorly tolerated and potentially daunting. Critically injured patients often develop hypothermia, acidosis, coagulopathy, and dysrhythmias, resulting in irreversible physiologic injury. Control of such damage is also part of the trauma surgeon’s armamentarium to deal with thoracic injuries. Progress in treating severe pulmonary injuries in critical patients has thus far relied on finding shorter, simpler, lung-sparing techniques, such as wedge and nonanatomic resections, and pneumonorrhaphy stapled and clamp tractotomy. In 1994, Wall described clamp pulmonary tractotomy to maximize pulmonary parenchymal salvage. Asensio in 1997 described the technique of stapled pulmonary tractotomy. The applicability of stapled pulmonary tractotomy was subsequently confirmed as a safe, valuable, lung-sparing procedure in a series of 40 patients. Subsequently, Cothren reported that lung-sparing techniques are associated with improved morbidity and mortality rates when compared with resection techniques.
Rapid progress and advancement in technology, including endoscopic instrumentation anesthetic techniques, have revolutionized thoracic surgery and ushered in the era of video-assisted thoracoscopic surgery (VATS). VATS has provided the trauma surgeon with an alternative method for accurate and direct evaluation of the lung parenchyma, mediastinum, and diaphragmatic injuries, with the advantage of simultaneously allowing definitive treatment of such injuries. VATS also has been demonstrated to be an accurate, safe, and reliable operative therapy for complications of lung trauma, including posttraumatic pleural collections.
In 2012, Asensio described the use of the argon beam coagulator as an effective adjunct to stapled pulmonary tractotomy. After stapled pulmonary tractotomy and selective vascular ligation have been performed, diffuse parenchymal oozing can be severe and contributory to ongoing blood loss. For these situations we have used the argon beam coagulator. This is performed by applying the argon beam coagulator approximately 1 cm away from the injured pulmonary parenchyma, running the beam in both a vertical and horizontal fashion to control bleeding from the large raw surfaces of the lung. This also has the added advantage of allowing small bronchi not amenable to direct suture control to be sealed. Use of the argon beam coagulator appears to be a safe and effective adjunct technology to stapled pulmonary tractotomy as a means of rapid hemorrhage control for penetrating pulmonary injuries causing deep intraparenchymal hemorrhage. Use of the argon beam coagulator is a useful adjunct in the trauma surgeon’s armamentarium and has been widely used since its description.
Incidence
The true incidence of pulmonary injuries is unknown and difficult to estimate from the literature. The chest, in forming such a large and exposed part of the body, is particularly vulnerable to injury. The anatomic complex formed by the lungs, pulmonary vessels, and bronchial tree so completely fills the thorax that penetration or contusion of the chest rarely occurs without injury. The reported incidence of pulmonary injuries in the civilian arena varies according to authors and institutions. In 1979, Graham reported a 1-year experience, consisting of 373 patients sustaining penetrating pulmonary injuries; of these, 91 patients (24%) underwent thoracotomy, although operative interventions on the lung itself were only required in 45 (12%) patients. In this series, the mere presence of posttraumatic hemothorax or pneumothorax was considered by the authors as clear evidence of traumatic pulmonary injury, which justified the inclusion of these cases in the study.
In 1988, Robison described a 13-year civilian experience in the management of penetrating pulmonary injuries in 1168 patients sustaining penetrating chest injuries; however, only 68 patients required thoracotomy to manage traumatic lung injury. In 1988, Thompson reported a 5-year experience of 2608 patients with thoracic trauma. Of the total, 1663 patients sustained injuries from blunt trauma and only 11 (0.7%) required thoracotomy; 945 sustained penetrating injuries and 15 (1.6%) required thoracotomy. Wiencek and Wilson reported a series consisting of 161 patients requiring thoracotomy for civilian penetrating pulmonary injuries during a 7-year period, which translates to 23 cases per year. Wagner described a 4-year experience of 104 patients with significant blunt chest trauma; 115 pulmonary lacerations were detected in 75 patients, for an incidence of 72%; 86% of these injuries were diagnosed by computed tomography (CT) scan, and 14% were detected by surgery. Based on both radiologic and surgical findings, the authors reported a higher incidence of traumatic pulmonary injuries compared with other clinical series that reported their results based only on surgical findings.
In 1993, Tominaga described a 7-year single institutional experience of 2934 patients sustaining both blunt and penetrating chest trauma; 347 patients (12%) required thoracotomy, and 12 (3.5%) in this subgroup required pulmonary resections. The mechanism of injury was blunt in 25%, and penetrating in 75% of cases, for an incidence of 0.04%, translating into 1.7 cases per year. Wagner in 1996 described an 8-year experience of 1804 patients admitted with chest trauma; 269 (15%) underwent thoracotomy, with 55 requiring operative interventions specifically for their pulmonary injuries, for an incidence of 3%, and an average of 6.9 patients per year.
In 1997, Stewart reported a 10-year experience consisting of 2455 patients with both penetrating and blunt chest trauma; 183 (7.4%) patients required thoracotomy, and 32 (17.4%) required pulmonary resection, which translates to 3.2 cases per year. Inci in 1998 reported a 5-year experience consisting of 755 patients sustaining penetrating chest trauma, of whom 61 (8.1%) required thoracotomy; however, specific operative interventions for penetrating pulmonary injuries were required in only 3 patients (4.9%), for an incidence of 0.6 case per year.
In 1998, Wall described a 3-year experience of 236 patients requiring thoracotomy for penetrating chest trauma; 90 (38%) required repair or resection to manage their pulmonary lacerations, for an average of 30 patients per year. In 2001, Karmy-Jones reported the findings of a multicenter 4-year review of five Level I trauma centers. A total of 43,119 patients were admitted for penetrating thoracic trauma, and 290 (2.8%) required thoracotomy; surprisingly, 115 patients (40%) in this subgroup underwent some type of lung resection. In a series of 4087 patients admitted for chest trauma, Cothren reported that 416 patients (10%) patients required thoracotomy and 36 (9%) required surgical interventions on the lung, for an incidence of 1% and an average of 3.3 patients per year.
In the military arena, Zakharia in 1985 reported 1992 casualties during the fighting in Lebanon; 1422 patients underwent thoracotomy for hemodynamic instability secondary to penetrating chest trauma, and pulmonary injuries were present in 210 (15%) patients, for an incidence of 11%. In 1997, Petricevic reported on 2547 casualties from the most recent Balkan war experience. During a period of 4 years, 424 patients (16%) sustained both blunt and penetrating chest wounds; among these patients, 81 (19%) underwent thoracotomy for pulmonary injury, for an incidence of 20 cases per year. In 2018, Asensio described 101 patients requiring thoracotomy for complex penetrating pulmonary injuries; 73 (72%) were due to gunshot wounds and 28 (33%) due to stab wound.
Incidence of patients actually requiring thoracotomy
The true incidence of pulmonary injuries is unknown and difficult to estimate from the literature. Martin in a review of the National Trauma Data Bank of the American College of Surgeons reported an approximate incidence of 0.08% for penetrating pulmonary injuries. Only a small number of patients sustaining penetrating pulmonary injuries actually require thoracotomy. The literature reports an incidence ranging from 9% to 15% with even fewer patients requiring pulmonary resections. Because of the low incidence of operative interventions required for the management of these injuries, few Trauma Centers and Trauma Surgeons have developed significant experience with their operative management. Similarly, because the incidence of these injuries is low, few reports appear in a sporadic fashion in the literature. Since the description of the stapled pulmonary tractotomy as a tissue-sparing technique and the utilization of the Argon beam coagulator as its adjunct, the number of resective pulmonary procedures has also significantly decreased.
Graham in 1979 reported a one-year series of 373 patients sustaining penetrating pulmonary injuries. However, operative interventions were required in only 45 (12%) of the patients. Robison in 1988 described a 13-year series consisting of 1168 patients sustaining penetrating chest injuries; however, only 68 (6%) required thoracotomy. Similarly, Stewart reported a 10-year experience consisting of 2455 patients admitted with both blunt and penetrating thoracic trauma, 183 required thoracotomy and only 32 (17%) required some means of pulmonary repair and/or resection.
Etiology
Most patients requiring thoracotomy for pulmonary injuries will have suffered penetrating mechanisms of injury—gunshot wounds, stab wounds, and shotgun wounds. Much less common are blunt thoracic injuries requiring operative intervention. In 2003, Huh reported a gradual rise in the incidence of blunt thoracic injuries, mostly from motor vehicle collisions requiring operative intervention, from 3% before 1994, to 12% in the latter period. In the series by Tominaga, blunt mechanism of injury accounted for 25% of all pulmonary injuries requiring surgical treatment. In the civilian arena, gunshot wounds represent the major penetrating mechanism for patients requiring surgical treatment; several authors have reported that gunshot wounds account for 33% to 80% of cases with penetrating pulmonary injuries, and stab wounds account for 17% to 67% of these injuries. Karmy-Jones, in a multicenter study on managing traumatic lung injuries, reported an increasing rate of thoracotomy among these patients. Other mechanisms such as impalement and shotgun wounds are reported with a lower frequency of 1% to 5% of cases.
Penetrating injuries account for the majority of patients requiring thoracotomy for pulmonary injuries. Karmy-Jones in a multicenter study reported that gunshot wounds accounted for 33% to 88% of these cases, while stab wounds accounted for 17% to 60% and other mechanisms such as impalements occurred at lower rates 1% to 5%. This is corroborated by both Huh and Tominaga. In the military arena Zakharia reported a high incidence of high-velocity gunshot wounds and shelling causing fragmentary injuries from the various Lebanese wars/conflicts. Petricevic reported the cause of pulmonary injuries during the war in Croatia, where explosive wounds prevailed (59%), followed by gunshot wounds (both high and low velocity, 37%), whereas other types of wounds—stabbing and falling—accounted for only 4% of cases.
In a series from 2018, Asensio reported on 101 patients who required thoracotomy for treatment of civilian penetrating pulmonary injuries. In this series, gunshot wounds accounted for most cases (72% of cases); stab wounds and other mechanisms (e.g., impalement, shotgun wounds) accounted for 33% and 5% of cases, respectively.
Latest literature—operative management and predictors of outcome
In 2018, Asensio and colleagues reported a very comprehensive study consisting of 101 patients with penetrating pulmonary injuries, all of which required emergent thoracotomy. There were 96 males (95%) and five females (5%), with a mean age of 30 ± 10.29. The mean Revised Trauma Score (RTS) was 6.25 ± 2.77, mean Injury Severity Score (ISS) was 36 ± 22, and the mean Abbreviated Injury Scale for chest was 3.97 ± 0.78. A total of: 73 (72%) sustained gunshot wounds and 28 (28%) sustained stab wounds.
Mean admission systolic blood pressure was 97 ± 47 mm Hg, mean admission diastolic blood pressure was 53 ± 34, mean admission heart rate was 98 ± 47 beats per minute, mean admission respiratory rate was 22 ± 11 breaths per minute, and mean admission temperature 35.8 ± 1.07° C. Predictors of outcome were identified for initial conditions on arrival, including systolic blood pressure ( p = .0019), respiratory rate ( p = .0043), RTS ( p < .0001), and admission pH ( p = .0014) (see Table 1 ). Arterial blood gases were obtained in 88 of the 101 patients (87%) revealing a mean pH of 7.22 ± 0.17 and a mean base deficit of -6.8 ± 5.8. The mean total volume of fluids administered in the emergency department (ED) was 2716 mL, including of 2076 ± 604 mL of crystalloids, and 540 ± 181 mL packed red blood cells. There were 9 (9%) patients that arrived in cardiopulmonary arrest, all required ED thoracotomy (EDT), aortic cross-clamping, and open cardiopulmonary resuscitation; 2 patients (22%) ultimately survived.
TABLE 1
Predictors of Outcome for Initial Conditions on Arrival for 101 Penetrating Pulmonary Injuries Requiring Emergent Thoracotomy
| Parameter | Survivor | Mean | SD | p Value |
|---|---|---|---|---|
| SBP |
|
|
|
.0019 |
| DBP |
|
|
|
.0235 |
| HR |
|
|
|
.0027 |
| RR |
|
|
|
.0043 |
| AIS |
|
|
|
.0001 |
| ISS |
|
|
|
.0001 |
| RTS |
|
|
|
.0001 |
| pH |
|
|
|
.0014 |
| PaO 2 |
|
|
|
.0051 |
| BE |
|
|
|
.0001 |
AIS, Abbreviated Injury Scale; DBP, diastolic blood pressure; HR, heart rate; ISS, Injury Severity Score; RR, respiratory rate; RTS, Revised Trauma Score; SBP, systolic blood pressure.
All patients were subsequently transported to the operating room (OR) for definitive surgical intervention. In the OR, 83 (84%) were intubated with a single lumen tube, 11 (11%) had double lumen tubes, and in 6 (6%), the type of endotracheal tube was not recorded. Most patients underwent anterolateral thoracotomy 83 (82%), 18 (18%) required median sternotomy, 4 (4%) underwent posterolateral thoracotomy, while another 4 patients (4%) underwent a combination of incisions other than median sternotomy.
OR findings confirmed the presence of pulmonary injuries in all patients. Anatomic distribution of injuries revealed 66 (65.3%) patients that sustained left lung injuries, while 35 (34.6%) sustained right lung injuries (see Table 2 ). There were 143 operative procedures required in 101 patients. Many required more than one technique for definitive repair and control of bleeding, for a total of 1.4 procedures per patient. There were a total of 32 (31%) pneumonorrhaphies, 41 (41%) stapled pulmonary tractotomies and/or wedge resections, 23 (23%) lobectomies, and 6 (5%) pneumonectomies. There were a total of 114 (80%) tissue-sparing versus 29 (20%) resective procedures. Pneumonectomy predicted mortality ( p = .024) (see Table 3 ).
TABLE 2
Predictors of Outcomes Stratified to Surgical Procedure for 101 Penetrating Pulmonary Injuries Requiring Emergent Thoracotomy
| Procedure (n) | Survivors | p Value |
|---|---|---|
| Nonanatomic (wedge) resection (41) |
|
.035 |
| Stapled tractotomy (41) |
|
.091 |
| Pneumonorrhaphy (32) |
|
.748 |
| Lobectomy (23) |
|
.205 |
| Pneumonectomy (6) | No: 5 Yes: 1 |
.024 |
TABLE 3
Anatomic Site of Injury and Operative Procedures Stratified to American Association for the Surgery of Trauma Organ Injury Scale grading Lung Injury Scale for 101 Penetrating Pulmonary Injuries Requiring Emergent Thoracotomy
| Anatomic Site of Injury | |
|---|---|
|
|
| Grade II (n = 11) | |
|
|
| Grade III (n = 51) | |
|
|
| Grade IV (n = 30) | |
|
|
| Grade V (n = 6) | |
|
|
| Grade VI (n = 3) | |
|
|
All injuries were graded utilizing the American Association for the Surgery of Trauma Organ Injury Scale (AAST-OIS) 16 lung injury scale. There were 11 (10.9%) grade II, 51 (50.5%) grade III, 30 (29.7%) grade IV, 6 (5.9%) grade V, and 3 (3.0 %) grade VI injuries. When comparing survival rates AAST-OIS injury grades I–III versus IV–V predicted survival ( p < .001). The more complex surgical procedures including resective procedures were required for the definitive management of higher injury grades (see Table 4 ).1
The mean estimated blood loss was 5277 ± 4455 mL. The total mean volume of intraoperative fluid replaced included 17,794 mL. This consisted of a mean total crystalloid volume of 6895 ± 4372 mL, and 961 ± 634 mL of colloids. The mean total volume of blood and blood products administered in the OR included packed red blood cells 3463 ± 2700 mL; whole blood 3300 ± 2693 mL; fresh frozen plasma 1724 ± 1413 mL; cryoprecipitate 220 ± 96 mL; and platelets 1541 ± 1868 mL. Intraoperative complications included acidosis in 49 (49%) patients, hypothermia in 40 (40%), dysrhythmias in 18 (18%), and coagulopathy in 12 (12%). Multiple intraoperative factors such as estimated blood loss were predictive of outcome ( p = .02) as was the presence of intraoperative dysrhythmias ( p = .0001) (see Table 5 ).
TABLE 5
Mortality Stratified to Surgical Procedure for 101 Penetrating Pulmonary Injuries Requiring Emergent Thoracotomy
| Procedure | Mortality, n (%) | Survival, n (%) |
|---|---|---|
| Pneumonorrhaphy | 11/32 (34%) | 21/32 (65%) |
| Wedge resection | 10/41 (24%) | 31/41 (76%) |
| Stapled tractotomy | 11/41 (27%) | 31/41 (73%) |
| Lobectomy | 11/23 (48%) | 12/23 (52%) |
| Pneumonectomy | 5/6 (83%) | 1/6 (17%) |
There were a total of 179 associated injuries for an average of 1.77 associated injuries per patient of which there were 39 (22%) thoracic and 140 (78%) of the intrathoracic injuries, there were 24 (24%) cardiac and 15 (15%) large vessel injuries. Associated cardiac injuries was a strong single independent predictor of outcome for mortality in stepwise logistic regression analysis ( p = 0.02, odds ratio 8.74, 95% confidence interval [CI] 1.37–55.79) (see Table 6 ). Associated intraabdominal injuries included diaphragmatic injuries 43 (42.5%), hepatic 26 (25.7%), gastric 19 (18.8%), splenic and small bowel 15 (14.8%), large bowel 9 (8.9%), and major abdominal blood vessels 7 (6.9%) as well as renal, duodenal, pancreas, gallbladder, and ureter all ranging from 1.9% to 5.9%.
TABLE 6
Stepwise Logistic Regression for 101 Penetrating Pulmonary Injuries Requiring Emergent Thoracotomy
| Significance ( p ) Value | Odds Ratio | 95% Confidence Interval | |
|---|---|---|---|
| AAST-OIS grades IV–VI | .007 | 6.38 | 1.64–24.78 |
| Intraoperative dysrhythmias | .003 | 17.38 | 2.59–116.94 |
| Associated cardiac injuries | .02 | 8.74 | 1.37–55.79 |
AAST-OIS, American Association for the Surgery of Trauma Organ Injury Scale.
A total of 64 (64%) patients survived for an overall survival rate of 64%. Adjusted survival rate excluding patients requiring emergency thoracotomy was 68%. Survival stratified to AAST-OIS injury grade revealed a higher survival rate for grades II–III versus IV–VI ( p < .001). Survival was also stratified to surgical procedures, with pneumonectomy incurring a very high mortality (83%) (see Table 6 ). One or more postoperative complications occurred in 22 (34%) patients, including infections/sepsis in 9 (14%), pneumonia in 7 (11%), hemorrhage in 5 (8%), bronchopleural fistula in 4 (6.25%), and empyema in 3 (4.7%). Seven (11%) required tracheostomy with a mean number of 24 ± 14 tracheostomy days. The mean total SICU length of stay was 5.54 ± 9.05, and the mean hospital length of stay was 11.7 ± 14 days.
Stepwise logistic regression analysis identified AAST-OIS injury grades IV–VI ( p = .007; odds ratio 6.38, 95% CI 1.64–24.78), presence of intraoperative dysrhythmias ( p = 0.003; odds ratio 17.38, 95% CI 2.59–116.94) and associated cardiac injuries ( p = .02; odds ratio 8.74, 95% CI 1.37–55.79) as the most important independent predictors of outcome for penetrating pulmonary injuries (see Table 7 ).
TABLE 7
Pneumonectomy Outcomes for Penetrating Injuries for 101 Penetrating Pulmonary Injuries Requiring Emergent Thoracotomy
| Author | Year | Patients | Deaths | Mortality (%) |
|---|---|---|---|---|
| Reul | 1973 | 4 | 2 | 50 |
| Fisher | 1974 | 4 | 1 | 25 |
| Hankins | 1977 | 1 | 1 | 100 |
| Grover | 1977 | 2 | 0 | 0 |
| Jones | 1984 | 2 | 0 | 0 |
| Bowling | 1985 | 8 | 6 | 75 |
| Thompson | 1988 | 9 | 9 | 100 |
| Wiencek | 1988 | 2 | 2 | 100 |
| Robison | 1988 | 3 | 3 | 100 |
| Tominaga | 1993 | 3 | 2 | 67 |
| Carrillo | 1994 | 9 | 6 | 67 |
| Baumgartner | 1996 | 9 | 7 | 78 |
| Stewart | 1997 | 4 | 2 | 50 |
| Kaseda | 1998 | 1 | 0 | 0 |
| Matsumoto | 1998 | 1 | 1 | 100 |
| Velmahos | 1999 | 3 | 3 | 100 |
| Deneuville | 2000 | 2 | 2 | 100 |
| Karmy-Jones | 2001 | 8 | 4 | 50 |
| Cothren | 2002 | 3 | 3 | 100 |
| Huh | 2003 | 33 | 23 | 70 |
| Asensio | 2018 | 6 | 5 | 83 |
| Total | 117 | 82 | 70 |
Asensio’s study describes one of the largest series, consisting of 101 patients with penetrating pulmonary injuries, all requiring emergent thoracotomy secondary to their clinical presentation with a low mean blood pressure of 97, RTS of 6.25, mean pH of 7.22, significant base deficit of 6.8, and a high ISS of 36, denoting a physiologically compromised and anatomically severely injured patient population.
This study describes and validates predictors of outcome for patients sustaining penetrating pulmonary injuries requiring surgical intervention. These predictors of outcome include physiologic condition upon arrival such as vital signs, pH, and base deficit. It is also worthwhile to note that the initial PaO 2 level after intubation was a strong predictor of outcome. Anatomically, the Abbreviated Injury Scale was also noted to be a strong predictor of outcome. To the best of our knowledge, this has not been previously reported. Also, to the best of our knowledge, no other series has validated or graded these injuries utilizing the AAST-OIS lung injury scale. Patients with AAST-OIS IV–VI had statistically significant higher mortality rates.
This study also described intraoperative predictors of outcome including estimated blood loss as well as the need for blood and blood products. Similarly, the presence of any intraoperative complications such as acidosis, hypothermia, or coagulopathy and the presence of dysrhythmias also predicted outcome.
Historically, penetrating pulmonary injuries were managed by resective procedures including both lobectomy and/or pneumonectomy. These procedures still carry significant mortality. Since the description of lung-sparing procedures by Asensio—stapled pulmonary tractotomy and the advent of the argon beam coagulator as an adjunct to tractotomy, also described by Asensio—decreases in both morbidity and mortality have been reported.
Velmahos and Cothren reported that up to 85% for their penetrating pulmonary injuries could be managed with tissue-sparing techniques. In this series, 80% of patients were managed with lung-sparing techniques; however, higher injury grades required resective techniques. The study by Karmy-Jones reported a higher mortality as the extent of resection increases. This correlation was validated in our study and was a strong independent predictor of outcome. Similarly, the need for pneumonectomy was highly predictive of mortality.
Martin reviewed the National Trauma Data Bank of the American College of Surgeons data of 669 patients and reported lower mortality rates for patients undergoing nonresective versus resective procedures, with mortality rates for lobectomy of 27% and pneumonectomy of 53%. In our series, lobectomy and pneumonectomy had 48% and 83% mortality, respectively. These differences may be accounted for by the much higher ISS of the patients in our series—36 versus 24 in Martin’s series—as well as by the higher number of thoracic and extrathoracic associated injuries.
Unfortunately, mortality rates for patients requiring pneumonectomy are very high, ranging from 50% to 100%. The vast majority of patients requiring pneumonectomy usually present in profound shock or already experiencing the exsanguination syndrome. In order to determine the true mortality of patients requiring pneumonectomy for penetrating injuries, we reviewed 20 series from the literature and included our own experience. There were a total of 117 patients, and 82 succumbed for a mortality rate of 70% (see Table 8 ). The mechanism responsible for this high mortality was proposed by Bowling, who postulated that these patients died due to acute right ventricular failure. This was confirmed in a porcine model by Cryer and has also been noted clinically by Asensio.
TABLE 8
Lung Injury: Organ Injury Scale, American Association for the Surgery of Trauma for 101 Penetrating Pulmonary Injuries Requiring Emergent Thoracotomy
| Grade * | Injury Type | Description † |
|---|---|---|
| I | Contusion | Unilateral, <1 lobe |
| II |
|
|
| III |
|
|
| IV |
|
|
| V | Vascular | Hilar vessel disruption |
| VI | Vascular | Total, uncontained transection of pulmonary hilum |
* Advance one grade for multiple injuries up to grade III. Hemothorax is scored under thoracic vascular organ injury scale.
† Based on most accurate assessment at autopsy, operation, or radiologic study.
Asensio’s overall survival rate excluding patients arriving in cardiopulmonary arrest requiring EDT was 68%, and compares favorably with rates reported in the literature, given the significant numbers of both thoracic and extrathoracic injuries, especially a 24% and 15% incidence of associated cardiac and large thoracic blood vessel injuries, respectively. The presence of an associated cardiac injury was a strong predictor of outcome in our series as well as in the series of Karmy-Jones.
In Asensio’s study, they reported predictors of outcome for penetrating pulmonary injuries that must be taken into account during their operative management, while validating the AAST-OIS lung injury scale. Tissue-sparing techniques may be utilized to manage between 80% and 85% of these patients as previously reported in the literature. According to our data, every effort should be made to utilize lung-sparing techniques. This study once again validates stapled pulmonary tractotomy as a valuable technique to manage these injuries. This procedure is now uniformly used worldwide and is estimated that approximately 85% of patients sustaining penetrating pulmonary injuries can be managed this way.
Unfortunately, lobectomy and pneumonectomy still carry significant morbidity and mortality as evidenced by our review of the literature. Because only a small percentage of penetrating pulmonary injuries require thoracotomy, for definitive management, the challenge of decreasing their mortality awaits a concentrated effort to develop animal models to define newer strategies within a translational model approach.
Classification
The AAST-OIS described the lung injury scale in 1994. This scale facilitates clinical research and provides a common nomenclature by which trauma surgeons may describe lung injuries and their severity. The grading scheme is fundamentally an anatomic description, scaled from 1 to 5, describing the least to the most severe injury. Thus far, studies have correlated injury grade with mortality rate for this study ( Table 1 ).
Diagnosis
The diagnosis of traumatic pulmonary injuries is established by physical examination and adjunctive diagnostic modalities.
Physical examination
The clinical presentation of patients who sustain pulmonary injuries ranges from hemodynamic stability to cardiopulmonary arrest. Physical examination yields a wealth of diagnostic information, which is used to indicate emergent interventions on these patients.
Patients with pulmonary injuries may present with symptoms and signs of pneumohemothorax or an open pneumothorax with partial loss of the chest wall. They may also present with a tension hemothorax or pneumothorax, or rarely, with a pneumomediastinum upon auscultation. Hamman’s crunch—a systolic crunch—may be detected upon auscultation in these patients. Similarly, they may also present with a pneumopericardium detected by auscultating Brichiteau’s windmill bruit (bruit de moulin). Patients with penetrating pulmonary injuries may rarely present with true hemoptysis. Occasionally, these patients present with symptoms and signs of an associated cardiac injury.
During the evaluation of these patients, the trauma surgeon must be cognizant that the thoracic cavity is composed of both right and left hemithoracic cavity as well as the anterior, posterior, and superior mediastinum, as often missiles or other wounding agents may traverse one or more of these cavities. Similarly, missile trajectories are often unpredictable and frequently create secondary missiles if they impact on hard bony structures (ribs, sternum, spine), thus creating the potential for associated injuries and greater damage.
Adjunctive diagnostic modalities
Adjunctive diagnostic modalities are divided into noninvasive diagnostic modalities and invasive diagnostic modalities.
Noninvasive diagnostic modalities
These diagnostic modalities include trauma ultrasound (focused assessment with sonography for trauma [FAST]), chest radiograph, CT, and electrocardiogram (ECG).
Trauma ultrasound
Trauma ultrasound is performed as part of the secondary survey of the trauma patient and remains a valuable diagnostic modality used to detect associated cardiac injuries as well as the presence of associated abdominal injuries in patients sustaining isolated chest trauma and multiply injured patients. In 2004, Kirkpatrick reported the use of sonography for detecting traumatic pneumothoraces and described this diagnostic strategy as extended FAST (E-FAST). Normal thoracic sonograms reveal comet-tail artifacts, originating from the sliding and reappositioning of the visceral pleura onto the parietal pleura during the ventilatory effort; posttraumatic pneumothoraces are diagnosed when comet-tail artifacts are absent. The authors enrolled 225 patients in this study and concluded that E-FAST has comparable specificity (99.1% vs. 98.7%) to chest radiography but was more sensitive (58.9% vs. 48.8%) for the detection of posttraumatic pneumothoraces. Knudson in 2004 performed 328 thoracic evaluations in trauma patients and described thoracic sonography having a specificity of 99.7%, a negative predictive value of 99.7%, and an accuracy of 99.4% when used for diagnosing posttraumatic pneumothorax. However, thoracic sonography was noted to be more sensitive (100% vs. 88.9%) and with a higher positive predictive value (100% vs. 88.9%) when used to diagnose posttraumatic pneumothoraces in patients sustaining penetrating versus blunt trauma, although the specificity (100% vs. 99.7%), negative predictive value (100% vs. 99.7%), and accuracy (100% vs. 99.3%) are comparable. On the basis of these findings, Knudson concluded that ultrasound is a reliable modality for the diagnosis of pneumothorax in the injured patient, and thus, it may serve as an adjunct or precursor to routine chest radiography in the evaluation of injured patients.
Sonography has also been employed to detect the presence of traumatic hemothorax. The technique for this examination is similar to evaluate the upper quadrants of the abdomen. The transducer is advanced to identify the hyperechoic diaphragm and to evaluate both right and left supradiaphragmatic spaces for the presence or absence of fluid. Sisley in 1998 evaluated 360 patients with suspected blunt or penetrating torso trauma, with 40 posttraumatic effusions, 39 (98%) of which were detected by sonography and 37 (93%) by chest radiography. The authors concluded that sonography is more sensitive (97.5% vs. 92.5%) than chest radiography for detecting posttraumatic effusions; however, a specificity of 97.5% in both studies is comparable. On the basis of these data, the authors concluded that surgeon-performed thoracic sonography is as accurate as, but significantly faster than, supine portable chest radiography for the detection of traumatic effusion.
Chest radiograph
A standard supine posteroanterior chest radiograph is the most frequently used diagnostic modality in patients who sustain traumatic lung injury. Radiologic diagnosis of traumatic pulmonary injuries by chest radiography is based on the presence of pneumothorax, pleural fluid collections, intrapulmonary hematomas, traumatic pneumatoceles, and pulmonary parenchymal contusions. Although chest radiography has been demonstrated to be 99% specific, it is a relatively insensitive test (49%) for the detection of posttraumatic pneumothorax; chest radiography has been demonstrated to possess a sensitivity of 93% and a specificity of 99.7% to detect posttraumatic pleural effusions.
When compared with CT, the conventional chest radiograph underestimates or overlooks both parenchymal and pleural injuries and has poor ability to determine the magnitude of pulmonary parenchymal compromise or pneumothorax size. Wagner demonstrated that pulmonary parenchymal lacerations are frequently missed by chest radiography.
Computed tomography
CT is found to be more sensitive than chest radiography for diagnosing traumatic pulmonary injuries. The most common types of abnormalities seen on CT scans include parenchymal lacerations, posttraumatic hemothorax, posttraumatic pneumothorax, atelectasis, subcutaneous emphysema, pneumopericardium and hemopericardium, and chest wall fractures. Additional diagnostic information related to the traumatic injury to the lung is usually supplied by CT scans, which can reliably detect the presence and extent of subtle or considerable parenchymal contusion.
As described by Karaaslan in 1995, CT scans are also able to detect the presence of associated thoracic and mediastinal vascular injuries, injuries to other thoracic great vessels, and extrathoracic injuries, associated cervical spine injuries, and intra-abdominal injuries in about 30% of cases.
Electrocardiogram
Nonspecific ECG abnormalities are often seen in trauma patients; some of these changes such as sinus tachycardia and ventricular and atrial extrasystoles are related to systemic factors such as pain, decreased intravascular volume, hypoxia, abnormal concentration of serum electrolytes, and changes in sympathetic or parasympathetic tone; however, in some cases, ECG may exhibit changes caused by associated injuries—most commonly penetrating or blunt cardiac trauma consisting of findings related to myocardial injury like new Q waves, ST-T segmental elevation or depression, conduction disorders such as right bundle branch block, fascicular block, atrioventricular nodal conduction disorders, and other arrhythmias (atrial fibrillation, ventricular tachycardia, ventricular fibrillation, sinus bradycardia, and atrial tachycardia).
ECG findings may suggest the presence of pericardial tamponade in patients sustaining chest trauma and traumatic lung injuries. Low QRS voltage is closely associated with the presence of a large or moderate pericardial tamponade (sensitivity of 0%–42%, specificity of 86%–97%), although PR segment depression and electrical alternans commonly are also present in this setting.
Invasive diagnostic modalities
Chest tubes
Chest tube placement may be diagnostic as well as therapeutic. After entering the pleural cavity, a finger is inserted, and depending on the position of the tract, the trauma surgeon may palpate the lung surface for the presence of contusion, the surface of the diaphragm for lacerations, and the pericardial sac to detect the presence of tamponade.
The nature and amount of the material draining from the tube are also important. The amount of blood evacuated upon initial placement of the chest tube may indicate the need for thoracotomy; persistent drainage of blood through the tube thoracostomy obligates the trauma surgeon to reassess the need for surgical intervention. Drainage of gastrointestinal contents implies an esophageal, gastric, or intestinal injury associated with a diaphragmatic laceration. An air leak implies an underlying lung laceration, and large air leaks may indicate bronchial disruption.
Associated injuries
Associated injuries are commonly seen in conjunction with penetrating pulmonary injuries. From 5% to 65% of patients sustaining traumatic injuries to the lung present with associated thoracic or extrathoracic injuries; the average number of associated injuries reported in the literature ranges from 0.5 to 1.9 injuries per patient. The presence of an associated injury is an important determinant of outcome. Gasparri reported the presence of associated cardiac injury and the need for laparotomy for associated abdominal injuries as factors determining the mortality rate, and Asensio determined that the presence of an associated cardiac injury is an independent predictor of outcome.
Graham reported the presence of 73 associated thoracic injuries among 91 patients requiring thoracotomy for the management of penetrating pulmonary injuries, for an average of 0.8 associated thoracic injuries per patient; the most commonly injured organs included the heart, at 27%; intercostals, 16%; subclavian vessels, 9%; and superior vena cava, 7%. The authors also reported the presence of 175 associated abdominal injuries among 89 of the patients requiring laparotomy for an average of 1.9 associated abdominal injuries per patient; the most frequently injured organs were the liver, 21%; spleen, 19%; stomach, 14%; and colon, 10%.
Robison described the presence of 14 associated injuries in 11 of 28 patients sustaining traumatic lung injuries requiring thoracotomy and pulmonary resection or hilar repairs. In this series, the authors reported a morbidity rate of 39% and an average number of 1.3 injuries per patient. Cardiac injuries were present in 11% of cases; the remaining associated injuries follow: thoracic great vessel, 7%; spinal cord, 7%; hepatic, 7%; pancreatic, 4%; colonic, 4%; spleen, 4%; gastric, 4%; and peripheral nerve, 4%.
Wiencek and Wilson described the presence of 35 major associated injuries among 19 of 25 patients with central lung injuries, for an incidence of 76% and an average number of 1.4 injuries per patient, with the heart (26%) and thoracic great vessels (21%) as the most frequently injured organs. Associated abdominal injuries requiring laparotomy were found in 58% of cases. Tominaga reported 10 associated injuries among 12 patients who required thoracotomy and lung resection for traumatic pulmonary injuries, for an average of 0.8 injuries per patient. Associated injuries included head injuries at 17%; intra-abdominal injuries requiring laparotomy, 33%; cardiac injuries, 25%; and great vessel injury, 8%. Petricevic reported a 4.5% incidence of associated injuries to visceral organs in patients sustaining chest trauma during the war in Croatia. Stewart described the presence of 30 associated injuries in 21 of 32 patients (65%) requiring thoracotomy and pulmonary resection for traumatic injuries to the lung, for an average of 1.4 injuries per patient; these injuries were stratified into abdominal, 30%; musculoskeletal, 30%; neurologic, 17%; cardiac, 7%; and other injuries, 17%.
Gasparri reported associated injuries in 41 (58%) of 70 patients requiring thoracotomy for penetrating lung injuries, with heart (20%), diaphragm (17%), and liver (11%) as the most common organs involved. Karmy-Jones reported 42 associated thoracic injuries among 115 patients requiring thoracotomy and lung resection for penetrating chest trauma, for an average of 0.36 injuries per patient.
Cothren reported 27 associated injuries in a series of 36 patients requiring thoracotomy for severe pulmonary injuries, for an average of 0.75 injuries per patient. Associated thoracic injuries were present in 33% of patients, and associated extrathoracic injuries represented 66% of the total. Huh reported that 28% of patients requiring operative interventions on the lung required a concomitant laparotomy for intra-abdominal injuries.
Asensio in 2018 reported a 169-month, single-center experience consisting of 101 patients requiring thoracotomy for penetrating pulmonary injuries. In this series, there were 193 associated injuries for an average of 1.9 injuries per patient. There were 39 (22%) associated injuries to the thoracic organs and 154 (79.7%) associated extrathoracic injuries. The most common thoracic organs involved were the heart (23.7%) and thoracic great vessels (14.8%), and the most common extrathoracic organs were the diaphragm (42.5%), liver (25.7%), and stomach (18.8%).
Asensio in 2018 described the presence of associated cardiac injuries as being strong, single, independent predictor of outcome for mortality ( p = .02; odds ratio 8.74, 95% CI 1.37–55.79) (see Table 6 ).
Anatomic location of injury
The anatomic location of pulmonary injuries is not commonly reported in either clinical or radiologic series. Graham reported a predominance of left-sided lung injuries at 52% compared with right-side lung injuries at 36%, with bilateral injuries present in 12% of patients. Wiencek and Wilson, in a series focusing on central/hilar traumatic lung injuries, reported an incidence of 15% of hilar traumatic disruptions among 161 patients sustaining penetrating lung trauma. Robison described the anatomic location of traumatic lung injuries requiring resective techniques for surgical management as follows: left lower lobe, 28%; right middle lobe, 22%; left upper lobe, including lingula, 22%; right upper lobe, 17%; and right lower lobe, 17%. The left pulmonary artery (25%) was the most commonly injured pulmonary vessel, followed by the right pulmonary artery (14%), right pulmonary vein (11%), and left pulmonary vein (7%). The results of this series showed that traumatic injuries presented a slight right versus left preference, although left-sided vascular injuries were more common compared with right-sided pulmonary vascular injuries, at 56% and 44%, respectively.
Huh reported that the location of the traumatic pulmonary injuries requiring operative intervention showed a slight predilection for the left side (50%), followed by the right side (47%) and bilateral injuries (3%). Asensio, in a 2018 report consisting of 101 patients requiring thoracotomy for complex penetrating pulmonary injuries, found the left lung to be a predominant location of penetrating injuries compared with the right lung (65% vs. 35%, respectively). The authors also reported the specific location of these injuries: left lower lobe, 40%; left upper lobe, 21%; right middle lobe, 19%; right lower lobe, 11%; lingula, 5%; and right upper lobe, 5%.
Management
Although recent reports of thoracic injuries in military actions have advocated early thoracotomy and aggressive management of pulmonary injuries with resection as opposed to the more conservative and traditional treatment with tube thoracostomy, the vast majority of thoracic trauma patients—75% to 85%—are successfully managed with placement of chest tubes and supportive measures. The combination of lung expansion, low intravascular pressures, and high concentration of tissue thromboplastin provides adequate hemostasis in most instances; however, 9% to 15% of patients require thoracotomy to achieve surgical hemostasis or effect necessary repairs. Of patients undergoing thoracotomy for hemorrhage, 3% to 30% have been shown to require lung resection for control of injuries.
The indications for thoracotomy in patients sustaining penetrating pulmonary injuries include the following:
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Cardiopulmonary arrest
- ■
Impeding cardiopulmonary arrest upon arrival at the ED
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Evacuation of 1000 to 1500 mL of blood upon initial placement of chest tube
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Evacuation of more than 1000 mL of blood upon placement of chest tube and ongoing blood loss
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Tension hemothorax
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Large retained hemothorax
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Massive air leak from the chest tube
Surgical decisions
For patients who present in cardiopulmonary arrest, it is mandatory to proceed to EDT. The placement of a chest tube in the right hemithoracic cavity is required. This may need to be extended into bilateral anterolateral thoracotomies. For patients who present with systolic blood pressure lower than 80 mm Hg, it is mandatory to insert bilateral chest tubes and resuscitate per the Advanced Trauma Life Support protocol. If the patient remains unstable, he or she should be immediately transported to the OR. If the patient stabilizes, a thorough workup should be instituted. For patients presenting with thoracoabdominal injuries, insertion of a chest tube or tubes is recommended. In patients who sustain abdominal and thoracic or thoracoabdominal injuries and require exploratory laparotomy, the trauma surgeon should reassess the need for thoracotomy in the OR.
Operative management
Emergency department thoracotomy
If the patient arrives at the ED in cardiopulmonary arrest, it is necessary to immediately proceed to EDT. The objectives of EDT follow:
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Resuscitation of agonal patients with penetrating cardiothoracic injuries
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Evacuation of pericardial tamponade if there is an associated cardiac injury
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Direct repair of cardiac lacerations if there is an associated cardiac injury
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Control of thoracic hemorrhage
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Prevention of air embolism
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Cardiopulmonary resuscitation, which may produce up to 60% of the normal ejection fraction
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Control of the pulmonary hemorrhage
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Cross-clamp of pulmonary hilum
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Cross-clamp of descending thoracic aorta
The technique for EDT is described here as it pertains to its use for patients sustaining penetrating pulmonary injuries arriving in cardiopulmonary arrest and should only be performed by surgeons who have had appropriate training in the performance of this procedure:
- 1.
Immediate endotracheal intubation and venous access are performed; simultaneous use of rapid infusion techniques complements the resuscitative process. Chest tube insertion in the right hemithoracic cavity is also simultaneous.
- 2.
The left arm is elevated, and the thorax is prepped rapidly with an antiseptic solution.
- 3.
A left anterolateral thoracotomy commencing at the lateral border of the left sternocostal junction and inferior to the nipple is carried out and extended laterally to the latissimus dorsi. In females, the breast is retracted cephalad.
- 4.
The incision is carried rapidly through skin, subcutaneous tissue, and the pectoralis major and serratus anterior muscles until the intercostal muscles are reached.
- 5.
The three layers of these interdigitated muscles are sharply transected with scissors. The pleura is then opened.
- 6.
Occasionally, the left fourth and fifth costochondral cartilages are transected to provide greater exposure.
- 7.
A Finochietto retractor is then placed to separate the ribs. At this time, the trauma surgeon should evaluate the extent of hemorrhage present within the left hemithoracic cavity. An exsanguinating hemorrhage with almost complete loss of the patient’s intravascular volume is a reliable indicator of poor outcome.
- 8.
The left lung is then elevated medially, and the descending thoracic aorta is located immediately as it enters the abdomen via the aortic hiatus. The aorta should be palpated to assess the status of the remaining blood volume.
- 9.
The descending thoracic aorta can be temporarily occluded against the bodies of the thoracic vertebrae.
- 10.
Before cross-clamping the descending thoracic aorta, a combination of sharp and blunt dissection commencing at both the superior and inferior borders of the aorta is performed, so that the aorta may be carefully encircled between the thumb and index fingers.
- 11.
Inexperienced surgeons usually commit the error of clamping the esophagus, which is located superior to the aorta. A nasogastric tube previously placed can serve as a guide in distinguishing the esophagus from the often somewhat empty thoracic aorta.
- 12.
A Crafoord-DeBakey aortic cross-clamp should then be placed to occlude the aorta.
- 13.
If a cardiac injury is present, the pericardium is then opened longitudinally above the phrenic nerve; pericardial clot and blood are evacuated and the cardiac injury repaired.
- 14.
If a pulmonary hilar hematoma or active hemorrhage is present, cross-clamping of the pulmonary hilum with a Crafoord-DeBakey cross-clamp may be necessary.
- 15.
If a parenchymal laceration is detected, it should be clamped with Duval clamps.
- 16.
If the initial injury is located in the right hemithoracic cavity, or the previously inserted chest tube returns large quantities of blood, or injury is encountered in the contralateral hemithoracic cavity, the sternum is transected sharply, and the left anterolateral thoracotomy is then converted to bilateral anterolateral thoracotomies.
- 17.
Ligation of one or both internal mammary arteries may be necessary if the left anterolateral thoracotomy has been extended to the right hemithoracic cavity.
- 18.
Aggressive ongoing resuscitation is needed with warm, pressure-driven fluids via rapid infusers while this procedure is ongoing.
- 19.
Defibrillation with internal paddles may be needed, delivering 10 to 50 J.
- 20.
Epinephrine may also be administrated into the right or left ventricle or systemically.
- 21.
If air embolism is suspected, the ventricles will need to be aspirated with 16-G needles.
- 22.
Occasionally the use of a temporary pacemaker might be needed but outcomes are very poor.
- 23.
If the patient is successfully resuscitated, immediate and expedient transportation to the OR is mandated for definitive repair of the pulmonary injury or injuries.
Effects of pulmonary hilar cross-clamping
Positive.
These effects include: (1) preservation and redistribution of remaining blood volume, (2) improvement in perfusion to contralateral uninjured lung, (3) control of hilar hemorrhage, and (4) prevention of air emboli.
Negative.
These effects include: (1) rendering the cross-clamped lung ischemic, (2) imposing a great afterload onto the right ventricle, and (3) decrease in oxygenation and ventilation to cross-clamped lung.
Unknown.
These effects include the length of safe cross-clamp time and incidence of pulmonary reperfusion injury to both the injured and uninjured lung.
Effects of thoracic aortic cross-clamping
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