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16 • Cardiac, Great Vessel, and Pulmonary Injuries 185
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DIAGNOSIS
Penetrating Trauma
In the rst two groups described earlier (i.e., normotensive
patient with proximity of wound and normotensive or hypotensive patient with hematoma on examination or on chest
x-ray), further radiologic studies are necessary. Patients in
the hypotensive group will require judicious resuscitation
in the emergency department before further imaging studies. Depending on the degree of hypotension, resuscitation should be limited to maintain the patient's mentation
and urine output and not a specic blood pressure to avoid
restarting bleeding or increase ongoing bleeding.
The purpose of additional imaging studies in this scenario
is to verify and localize the aortic or arterial injury and to
help determine the most appropriate management. CT arteriography (CTA) is indicated because of convenience, speed,
and improved accuracy. Should the CTA be compromised by
scatter from metallic bullet fragments, a transfemoral digital subtraction aortogram is performed.
Regardless of chest x-ray ndings, no additional diagnostic studies are indicated in the third group of patients
with profound hypotension. Instead, patients with this
injury pattern and clinical presentation should have manual compression of any bleeding from the suprasternal or
supraclavicular area, initiation of blood component–based
resuscitation and be transported directly to the OR. Patients
with a systolic blood pressure less than 70 mm Hg or with
a recent cardiac arrest should have a resuscitative thoracotomy in the emergency department as described in previous
sections.
Blunt Trauma
Diagnosis of a blunt injury to the innominate, subclavian,
or common carotid artery proceeds in much the same manner as with patients who have a penetrating injury. An
initial chest x-ray is useful as a screening test to assess for
the presence of a hemothorax and/or a widened mediastinum indicative of a hematoma. Once again, CTA is used to
determine the presence and extent of a suspected injury in
a patient who is hemodynamically normal.
a range of vascular thoracic injuries when endovascular
approaches were applied. Other studies on this topic support these ndings.
71,73
Although comparatively less well-studied, endovascular
capabilities can also be utilized to support open repair in
a “hybrid” approach. For example, endovascular balloons
can provide temporary control of arteries both proximal
and distal to the injury site during open exposure (see Chap-
ter 11). Once in position, these balloons can frequently be
palpated within the operative eld, facilitating rapid identication of vascular structures in what can be a severely
disrupted eld of exposure due to the injury. It is important
to remember, however, that these approaches require the
availability of specialized providers and imaging capabilities, “luxuries” that are not often afforded in the setting of
an unstable patient.
Although the application of endovascular approaches
appears to have improved outcomes in select patients, there
also remains a paucity of data on long-term outcomes. The
need to collect these data is critical to dening the optimal
indications and techniques in the management of injuries
to the great vessels.
OPERATIVE MANAGEMENT IN THE EMERGENCY
DEPARTMENT AND OPERATING ROOM
Finger Control of External Hemorrhage
On rare occasions, external hemorrhage from either the
suprasternal notch or the supraclavicular fossa may be the
sole manifestation of a major thoracic vascular injury from
a stab or gunshot wound. If no pleural connection is present, insertion of a nger, balloon catheter, or pack into the
stab or gunshot wound site may control bleeding until the
patient can be transferred to the OR.
ENDOVASCULAR MANAGEMENT
The use of endovascular techniques to treat blunt and
penetrating thoracic aortic and side branch injuries has
increased exponentially since the early 2000s.
16.14). A growing body of evidence suggests that, among
appropriately selected patients, endovascular treatment
is associated with improved outcomes for injuries in these
areas which are often associated with challenging exposures for control and repair.
In the study by Branco et al., investigators found that
endovascular treatment for injuries to the axillary or
subclavian arteries was associated with lower in-hospital
mortality and fewer surgical site infections compared with
those managed with open repair.74 A subsequent report
utilizing data from the American College of Surgeons
National Trauma Data Bank compared matched cohorts
of patients with injuries at these locations who underwent either open or endovascular repair.72 In this study,
the authors found that outcomes were improved across
68–74
(Fig.
Fig. 16.14 A patient with blunt trauma to the chest had a traumatic
false aneurysm of the innominate artery on an arteriogram.
186 SECTION 4 • The Management of Vascular Trauma
Compressed
incision
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Incisions
The emergent approach to a patient who is hypotensive or
who has had a recent cardiac arrest from a wound to a great
vessel is a unilateral or bilateral anterolateral thoracotomy.
The only change that may be needed from the previously
described approach is to place the thoracic incision or incisions above the male nipple if there is an obvious wound,
a pulsating hematoma, or external bleeding in proximity
to the subclavian vessels. Although it is more difcult to
spread the ribs at this level, it does allow for rapid insertion
of a nger or pack to control intrapleural hemorrhage from
an injury to a subclavian vessel. After the bilateral anterolateral thoracotomy is performed, bimanual dissection is
performed to separate the upper chest ap and sternum
from the underlying thymus and pericardium. Finochietto
retractors are placed bilaterally, and a nger or clamp is
used to control bleeding.
A median sternotomy is performed in the OR in patients
who are more hemodynamically stable and when the track
of a stab or gunshot wound is in proximity to the superior
mediastinum (i.e., supraclavicular notch or zone I of the
neck). The same incision is used when the initial chest x-ray
documents a hematoma in the superior mediastinum. A
sternotomy provides great exposure to the ascending and
transverse thoracic aorta, innominate artery and veins,
the rst portion of the right subclavian artery, the proximal
right common carotid artery, and the proximal left common
carotid. A high left anterolateral thoracotomy is the preferred emergency approach to an injury to the rst (intrathoracic) portion of the left subclavian artery, though this
can be visualized with some effort through a sternotomy by
experienced surgeons. (Fig. 16.15).
Injury to the second portion of either subclavian artery
(posterior to the scalenus anticus muscle) is approached via
a supraclavicular incision. If the injury is directly behind the
clavicle or at its midpoint, a claviculotomy or resection of the
middle one-third of the clavicle may be useful in facilitating
control and repair (Fig. 16.16). Before claviculotomy or partial resection of the clavicle, circumferential stripping of the
periosteum is performed to separate away the often tightly
adherent subclavian vein. At the completion of the vascular
subclavian
artery
Clamped
subclavian
artery
Chest
Fig. 16.15 A high left anterolateral thoracotomy, cross-clamping of
the first portion of the left subclavian artery, and external compression to control exsanguinating hemorrhage from the second portion.
(With permission from Feliciano DV, Graham JM. Major thoracic vascular
injury. In: Champion HR, Robb JV, Trunkey DD, eds. Robb & Smith's Operative
Surgery. London: Butterworth & Co.; 1989.)
Fig. 16.16 Subperiosteal resection of the middle one-third of the clavicle improves exposure of the second portion of the subclavian artery and of the
adjacent subclavian vein. (Copyright, Baylor College of Medicine, Houston, 1985.)
Subclavian
artery
Clavicle (cut)
16 • Cardiac, Great Vessel, and Pulmonary Injuries 187
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repair, the claviculotomy may be repaired by drilling holes in
an anteroposterior direction in the ends. With this maneuver,
a sternal wire is curved into the letter “U,” is placed posteroanterior, and the two ends are twisted to align or approximate the divided ends of the bone. Another repair technique
is to use a dynamic compression plate across the anterior
aspect of the fracture. When a segment of clavicle has been
removed, inserting a sternal wire across each “fracture” site
is the quickest repair. Repair of the divided clavicle should be
performed in patients who are hemodynamically stable.
Should there be a need to expose the junction of the rst
and second portions of the subclavian artery on the right
side, it may be necessary to perform a median sternotomy
connected to a right supraclavicular incision. On the left
side, a high left anterolateral thoracotomy, a left supraclavicular incision, and a connecting partial upper median
sternotomy may occasionally need to be performed (Fig.
16.17). This rarely used “book thoracotomy” will, of course,
not open like a book. Rather, it slides open once a Finochietto retractor is inserted. The disadvantages of this incision
include multiple sharp bony ends that catch the gloves of
the surgical team and signicant postoperative pain.
Injury to the third portion of either subclavian artery
(lateral edge of scalenus anticus muscle to anterior edge of
rst rib) cannot always be approached through the supraclavicular incision. An infraclavicular incision may also
need to be performed adjacent to the lateral 1/3 of the
clavicle, as well. Connecting the supra- and infraclavicular
Fig. 16.17 Multiple incisions used for wounds to the great vessels.
Exposure of the first portion of right subclavian artery may require a
median sternotomy and right supraclavicular incision. Exposure of the
junction of the first and second portions of the left subclavian artery
may require a high left anterolateral thoracotomy, a partial upper
median sternotomy, and a left supraclavicular incision—the so-called
“book thoracotomy.” (Copyright Baylor College of Medicine 1980. With
permission.)
incisions and dividing the clavicle, if necessary, allows for
distal control at the rst portion of the axillary artery.
Control of Hemorrhage/Vascular Repair
Penetrating Wound of the Ascending Aorta or
Transverse Aortic Arch. After opening the pericardium,
pulsatile hemorrhage from the thoracic aorta is controlled
with a nger or a Satinsky or a large Wiley “J” clamp.75
Either of these clamps may be placed as a partial occlusion
clamp isolating the vascular injury for débridement and
repair. Aortorrhaphy is performed with a continuous or
interrupted row of 4-0 polypropylene sutures placed under
the surgeon's nger or above the Satinsky clamp. During
these maneuvers it is useful to reduce the patient's blood
pressure and stroke volume to avoid dislodgment of the
clamp and tearing of the sutures. The use of Dacron or
Teon pledgets as previously described may also assist in
repairing arterial injuries in this location.
Repair of Penetrating Wound of the Innominate
Artery. After performing a pericardiotomy, the crossover
left innominate vein is rapidly mobilized and elevated
superiorly or inferiorly with a Silastic vessel loop. This
vein may be ligated if necessary if it has been injured or is
obstructing exposure of the injured artery. Finger control
on a perforation of the artery is maintained until proximal
and distal vascular clamps (e.g., DeBakey, Satinsky, or Wiley
J) are applied. A wound near the distal bifurcation of the
innominate artery may be difcult to visualize through a
standard median sternotomy. In such a patient, the median
sternotomy may be extended cephalad with an oblique right
cervical incision or laterally with a right supraclavicular
incision, as previously noted. These extensions of the
sternotomy will allow for distal control of the right common
carotid and right subclavian arteries, respectively.
Dissection around the proximal right subclavian artery
should be done with care as the right recurrent laryngeal
nerve loops around this vessel within 1.5 to 3.0 cm of its
origin. Once vascular control has been obtained, an effort
should be made to convert clamping of the right subclavian
and common carotid arteries to just the distal innominate if
there is room. This maneuver allows for temporary perfusion
of the right upper extremity via backow through the right
common carotid artery from the circle of Willis in the brain.
If a short segmental resection of the innominate is necessary for a through-and-through gunshot wound, an endto-end and often pledgeted anastomosis is performed with
5-0 polypropylene suture. A longer segmental resection
mandates the insertion of an 8- or 10-mm ringed polytetrauoroethylene (PTFE) or knitted Dacron interposition graft.
As previously noted, temporary vascular shunts are not
usually inserted during end-to-end anastomoses or insertion of interposition grafts in this location or the common
carotid arteries unless a “damage control” operation is performed (Fig. 16.18). This is because there is almost always
adequate cerebral crossover ow in young patients if vascular clamp time is under 30 minutes.
As the end-to-end anastomosis or suture line on the distal
graft is completed, proximal and distal ushing is necessary
to remove air before the nal sutures are tied. The proximal clamp and a clamp on the right common carotid are
then reapplied as backow from the right subclavian artery
completes the evacuation of air. Antegrade ow is rst
188 SECTION 4 • The Management of Vascular Trauma
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established into the right subclavian artery by removing the
clamp on the innominate artery. Flow into the right common carotid artery is established 10 seconds later by removing the clamp on this vessel. Depending on the location of
an interposition graft, the proximal suture line may lie on
Fig. 16.18 Patient with near-exsanguination from a gunshot wound to
the proximal right common carotid artery had insertion of a temporary
intraluminal shunt during the initial “damage control” operation.
top of the trachea. An effort should be made to interpose
thymic tissue or pericardial fat between these structures so
as to prevent development of a tracheo-innominate artery
stula.
Repair of a Blunt Tear of the Innominate Artery
Origin. The proximal ascending aorta inferior to the origin
of the innominate artery is rst exposed, and an 8-mm knitted
Dacron graft is sewn to it using a partial occlusion clamp
(Satinsky or Wiley J) and a 4-0 polypropylene suture (Fig.
16.19). The hematoma (true or false traumatic aneurysm)
around the proximal innominate artery is not entered until
the aortic arch at the origin of the artery and its bifurcation
in the right superior mediastinum have been dissected free.
At this point a partial occlusion clamp is again placed on the
arch, this time around the origin of the innominate artery.
Another vascular clamp is placed around the distal artery,
or the right subclavian and common carotid arteries are
clamped individually. The hematoma is then entered, and the
distal innominate is transected.
At this juncture, the previously inserted PTFE or Dacron
graft, which has been cut longer than necessary, is sewn
end-to-end to the distal innominate artery (Fig. 16.19)
using 4-0 or 5-0 polypropylene suture. No shunt is used in
the “routine” operation as previously noted. On rare occasions, profound intraoperative hypotension may force the
surgeon to insert a temporary intraluminal shunt through
the proximal graft anastomosis and then withdraw it before
completion of the distal anastomosis. Systemic doses of
intravenous heparin are not generally used in patients
with this pattern of vascular trauma, especially those who
have suffered blunt injuries. The nal step in this approach
is the oversewing of the proximal innominate artery over
the partial occlusion clamp on the aortic arch. This suture
Fig. 16.19 Operative technique of bypass grafting for repair of blunt injury to proximal innominate artery. (Copyright, Baylor College of Medicine,
Houston, 1981.)
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line is easily visualized by moving the somewhat redundant
Dacron graft away from the arch.
Repair of a Blunt Tear of the Left Common Carotid
Artery Origin. After performing a pericardiotomy, the
crossover left innominate vein is mobilized and elevated
superiorly or inferiorly with a Silastic vessel loop. This vein
may be ligated if it has been injured or is obstructing an
otherwise challenging dissection. A Satinsky or Wiley J
clamp is applied in a longitudinal direction to the transverse
aortic arch just under the origin of the left common carotid
artery. The type of repair will depend on the amount of local
disruption of the intima and media at the junction of the
left common carotid artery and transverse arch. An obvious
extensive disruption of the origin of the left common carotid
artery is repaired as described for proximal blunt disruption
of the innominate artery using a separate inow site for an
interposition graft.
Right and Left Subclavian Vessels. When penetrating
wounds of the subclavian vessels communicate with the
corresponding pleural cavity, rapid exsanguination will
occur. In such patients, a high anterolateral thoracotomy at
the level of the 3rd or 4th intercostal space above the nipple
should be performed. Finger or pack control at the apex of
the right pleural cavity through the high right thoracotomy
coupled with manual pressure on the right supraclavicular
fossa will tamponade almost all major subclavian bleeding
until vascular control can be obtained in the OR.
As the proximal left subclavian artery is an intrathoracic structure (in contrast to the mediastinal course of the
proximal right subclavian), it can be visualized and directly
clamped through a high left anterolateral incision. If backbleeding from the distal artery or bleeding from the left subclavian vein continues, nger or pack pressure through the
thoracotomy incision should be combined with supraclavicular pressure, as described for the right side.
Proximal and distal control of the subclavian artery is
obtained after mobilizing the phrenic nerve away and dividing the scalenus anticus muscle. Depending on the location
of the injury, it may be necessary to ligate and divide the
thyrocervical trunk and, on occasion, the vertebral artery.
For future cardiac surgery, it is worthwhile to preserve the
ipsilateral internal mammary artery if possible. Experienced trauma vascular surgeons know that the subclavian
artery is fragile and that tension on an end-to-end anastomosis or graft anastomosis will lead to partial or complete
disruption of the suture line when ow is reestablished. If
an end-to-end anastomosis cannot be performed because of
tension after a segmental resection, an 8-mm ringed PTFE
or knitted Dacron interposition graft should be used as the
method of reconstruction.
Proximity and adherence of the subclavian vein to the
clavicle and the many venous branches in this area make
obtaining venous control and a satisfactory vein repair
challenging. If control of the subclavian vein is too difcult
or if repair results in extensive narrowing, ligation may be
a better choice. After ligation has been performed, the pressure should be measured in the supercial volar compartment of the ipsilateral forearm. A compartment pressure
greater than 35 mm Hg is followed by forearm fasciotomies
of the mobile wad and supercial and deep volar compartments through a volar–ulnar incision.76 The pressure is
then measured in the dorsal compartment of the forearm
to see if a fasciotomy is needed there, as well. If a claviculotomy or partial clavicular resection has been performed,
care must be taken to ensure that the tips of the screws used
for a bony repair do not protrude posteriorly near the artery,
vein, or repair.
Superior or Inferior Vena Cava. After performing a
pericardiotomy, DeBakey forceps are used to elevate the
perforated edges of the lacerated vein. A Satinsky clamp
is then placed under the perforation. As previously noted,
a row of Allis clamps may also be used to control bleeding
and elevate the edges of a long anterior, medial, or lateral
laceration. A through-and-through wound to the cava
mandates clamp control around the lacerations and repair
of the posterior perforation through the anterior opening,
followed by repair of the anterior injury. Venorrhaphy using
4-0 or 5-0 polypropylene suture in a continuous fashion is
the favored method of repair for the vena cava.
When clamp control of an extensive posterior perforation
of the inferior vena cava is impossible, the patient will need
to be placed on cardiopulmonary bypass. In this scenario,
the inferior cannula is placed in the inferior vena cava in
the abdomen via the femoral vein and a balloon catheter occludes the inferior vena cava beyond the injury.59
Posterior repair with 4-0 or 5-0 polypropylene suture is
completed through a right atriotomy.
Crossover Left Innominate Vein. After performing a
pericardiotomy, vascular clamps are placed around any
perforation in the left innominate vein. Either a lateral
venorrhaphy or end-to-end anastomosis is performed with
a 5-0 polypropylene suture. Ligation may be performed with
more extensive injuries or as an expedited damage control
maneuver. If the vein has been ligated, the pressure is then
measured in the supercial volar compartment of the left
forearm as previously described. In these instances, it may
be useful to place the left upper extremity in a stockinette
to facilitate intermittent elevation to reduce swelling during
the postoperative period.
MAJOR COMPLICATIONS
Cardiac Compression with Sternal Closure
As previously noted, temporary coverage of the heart can
be accomplished by sewing a plastic silo to the skin edges of
an anterolateral thoracotomy or median sternotomy. Once
the patient's physiology improves and diuresis occurs, the
silo is removed and the sternum closed at a reoperation.
Cerebral Ischemia
Cross-clamping of the innominate or left common carotid
artery in the hypotensive patient has the risk of leading to
cerebral ischemia and stroke. Fortunately, this complication is uncommon if control of hemorrhage, innominate
or carotid clamp time, and vascular repair are performed
quickly. If a patient has a persistently depressed Glasgow
coma scale score in the ICU after a repair of an injured
innominate, right or left common carotid artery, he or she
should undergo a CT scan of the brain. Ipsilateral cerebral
ischemia on the CT is treated with the avoidance of hypotension and hypoxia. Secondary cerebral edema is managed
with elevation of the patient's head, intravenous mannitol
(1 g/kg), drainage of cerebrospinal uid, and, on rare occasions, with pentobarbital coma.
190 SECTION 4 • The Management of Vascular Trauma
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Associated Neurological Deficits
The proximity of the brachial plexus to the supraclavicular
area explains the fairly high incidence of neurological decits associated with subclavian vascular trauma. Transected
trunks, divisions, or cords noted at the time of operation
should be tagged with long 0 or 2-0 polypropylene sutures
to allow for identication at a subsequent operation. A careful neurological examination should be performed and documented once swelling and pain from the acute injury and
operation have resolved. Persistent and severe decits in the
ipsilateral upper extremity mandate referral to a neurosurgeon with experience in neural grafting. If this is not possible,
referral of the patient to an upper extremity or hand surgeon
for possible tendon transfers in the forearm is appropriate.
SURVIVAL
Much as with cardiac injuries, survival after injuries to
the great vessels depends on multiple factors, including
mechanism (penetrating vs. blunt), number of signs of
life on admission, location of thoracotomy, presentation
(hemorrhage vs. hematoma), number of vessels injured,
and number of associated injuries. Survival gures
in large series over the past ve decades are listed in
Table 16.6.
66,68,74,77,78
Injuries to the Lungs
CLASSIFICATION
Injuries to the lungs are classied according to the AAST
Lung Organ Injury Scale described in 1994 (Table 16.7).
Table 16.6 Survival Rates After Injuries to the Great
Vessels.
Injuries Survival Rates
Injury to innominate artery, 1964–92 (penetrating 34/
blunt 7/other 2)
Gunshot/stab 72%
Blunt 86%
Penetrating injury to subclavian artery, 1991–2001
(gunshot 46/stab 5/shotgun 3)
Gunshot 73%
Stab 80%
Shotgun 80%
Penetrating injury to subclavian artery, 1997–2007
(stab 53/gunshot 4)68—all stentgraft
Survival 98% (#56)
Early occlusion 5% (#3)
Late occlusion 5% (#3)
Late stenosis 9% (#5)
Penetrating injury to innominate, carotid,
subclavian, and axillary arteries, 2000–13
Injury to axillosubclavian arteries, 2003–13
(penetrating 41, blunt 112)
Overall survival 78% (119/153)
Endovascular survival 94% (17/18)
Open survival 76% (102/135)
66
77
78
74
85%
25
HISTORY
Asensio et al. have comprehensively reviewed the history of
the management of pulmonary injuries.79 After the introduction of median sternotomy by Duval in 1897 and left
anterolateral thoracotomy by Spangaro in 1906, it was
American surgeons who developed operative repair of
major injuries to the lung during World War I. The overwhelming number of penetrating chest wounds in World
War II prompted use of drainage with thoracostomy tubes
as primary treatment.
80,81
This continues today with the
more invasive thoracoscopy or thoracotomy reserved for a
selected group of patients to be described.
INCIDENCE
Penetrating Trauma
Penetrating injury, 70% to 75% of which is gunshot related,
accounts for 75% to 88% of thoracotomies for thoracic
trauma in the United States.
79,82
When all patients with
penetrating wounds to the chest are considered, only 5%
to 10% have bleeding from the lung as the indication for a
thoracotomy as previously noted.
Table 16.7 Lung Organ Injury Scale.
GradeaInjury Type
I Contusion Unilateral, <1 lobe 861.12/861.31 3
II Contusion Unilateral, single
Laceration Simple
III Contusion Unilateral >1 lobe 861.20/861.30 3
Laceration Persistent
Hematoma Nonexpanding
IV Laceration Major (segmental
Hematoma Expanding
Vascular Primary branch
V Vascular Hilar vessel
VI Vascular Total, uncontained
AIS-90, Abbreviated Injury Scale; ICD-9, International Classification of
Diseases.
a
Advance one grade for bilateral injuries; hemothorax is graded according
to the thoracic vascular OIS.
b
Based on most accurate assessment at autopsy, operation, or radiologic
study.
From Moore EE, Malangoni MA, Cogbill TH, et al. Organ injury scaling IV.
Thoracic vascular, lung, cardiac, and diaphragm. J Trauma. 1994;36:
299–300.
Injury
Description
lobe
pneumothorax
(>72 hours), air leak
from distal airway
intraparenchymal
or lobar) airway
leak
intraparenchymal
intrapulmonary
vessel disruption
disruption
transection of
pulmonary hilum
25
b
ICD-9 AIS-90
861.20/861.30 3
860.0/1 3
860.4/5
860.0/1 3–4
860.4/5
862.0/861.30
862.21/861.31 4–5
901.40 3–5
901.41/901.42 4
901.41/901.42 4
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Blunt Trauma
Only 12% to 25% of patients undergoing a thoracotomy for
trauma to the lung have a blunt mechanism of injury.
79
ETIOLOGY
Penetrating Trauma
Gunshot and/or stab wounds lacerate the parenchyma of
the lung. Exsanguinating hemorrhage from a lung injury is
uncommon, especially if the wound is in the periphery of a
lobe. The relatively low incidence of bleeding from a pulmonary parenchymal injury is a reection of the relatively low
systolic pressure in the branches of the pulmonary artery.
This may also be due to a tamponade effect as the visceral
and parietal pleura come into contact with one another
after insertion of a thoracostomy tube.
Penetrating wounds that injure the more central, hilar
area of a lobe or the lung are more likely to cause lifethreatening bleeding. The obvious reason relates to the larger
size of more central vessels as well as the increased likelihood
that branches of both the pulmonary artery and vein will be
injured. It is also true that central vessels are extraparenchymal, making them more prone to free bleeding if lacerated.
Blunt Trauma
It is unusual for an adult to have an injury to the lung with
an associated pneumothorax or hemothorax without an
injury to the overlying ribs. In other words, most blunt pulmonary injuries are associated with rib fractures. The same
is not true for children, who are more susceptible to blunt
pulmonary injury without rib fracture due to the elasticity
of the thoracic cage. In addition to the mechanism of direct
laceration from the end of a fractured rib, there are two
other proposed mechanisms for blunt pulmonary injury.
The second is the valsalva-compression scenario in which
a patient inspires and holds his or her breath just before
compression occurs during a motor vehicle crash. This
phenomenon is thought to be associated with rupture of
the pulmonary parenchyma and pneumothorax. The third
mechanism relates to the differential deceleration of the
xed (hilum and inferior pulmonary ligament) versus
the mobile (peripheral parenchyma and lobes) aspects of
the lung in frontal deceleration or lateral impact. In these
scenarios, the pulmonary vasculature at these junction
points is prone to tearing or disruption.
PRESENTATION
Pneumothorax
Either penetrating or blunt thoracic trauma can cause a simple, tension, or open pneumothorax. A patient with a simple
pneumothorax (does not expand with inspiration) is likely to
present with pain from an associated rib fracture and with
shortness of breath. The severity of the dyspnea is related
to the size of the pneumothorax and extent of injury to the
underlying lung. Trainees have historically underestimated
the three-dimensional magnitude of a pneumothorax with a
collapsed lung. For example, should the radius of an injured
lung decrease from 10 to 8 cm secondary to a pneumothorax,
the volume of the lung as a sphere (πr3) would decrease by
50%. If one prefers to consider the injured lung as a cylinder
(πr2h), a decrease in the radius of 10 to 8 cm in a structure
30 cm in height would decrease volume by 36%.
A patient with an open pneumothorax or what is sometimes referred to as a “sucking chest wound” has an opening
in the chest wall and pleura that is larger than the opening in
the glottis. In this scenario, when the patient takes a breath,
air will enter the pleural space around the lung rather than
enter into the lung through the tracheobronchial tree (i.e.,
breathing through the chest wall). Such a patient will present with the sound of air movement through the chest wall
defect, shortness of breath, and possibly hypotension related
to tension physiology including mediastinal shift.
A patient with a true tension pneumothorax is rare in
the emergency department presumably because of the
prehospital lethality of such an injury. In the modern era,
most patients with this entity are in the ICU on a volume
ventilator and often with ventilator-associated pneumonia
that predisposes to pulmonary rupture. A tension pneumothorax leads to anxiety and a sense of doom, absent breath
sounds, hyperresonant percussion on the affected side, and
deviation of the trachea away from the pneumothorax.
Cyanosis is an ominous sign often manifest shortly before
cardiovascular collapse secondary to tension physiology.
Hemothorax
Hemothorax or blood in the pleural cavity results from
injury to a vessel in the pulmonary circulation, a vessel in
the systemic circulation (e.g., intercostal or internal mammary vessel), or an injury to the heart. In all three instances,
symptoms from a hemothorax will be related to its volume
and whether any bleeding is ongoing. As such, both respiratory (e.g., shortness of breath) and hemodynamic compromise (e.g., hypotension) may occur.
DIAGNOSIS
A patient with signicant thoracic trauma, shortness of
breath, and decreased or absent breath sounds over one
hemithorax has a presumed pneumo- or hemothorax. In
the presence of all three symptoms, no further diagnostic
study is indicated other than insertion of a thoracostomy
tube. In a patient with an altered sensorium, traumatic
brain injury, or multiple injuries, or one in whom bilateral
breath sounds are difcult to assess, a surgeon-performed
transthoracic ultrasound of the lungs should be performed.
This extended FAST examination (EFAST) is accomplished
with a 3.5-mHz general transducer probe positioned over
the lateral thorax, superior to the 10th and 11th intercostal spaces. This technique can be used to quickly determine the presence of a pneumo- and/or hemothorax.
Blood in the thoracic cavity appears as a V-shaped stripe on
ultrasound that is isoechoic compared to the blood in the
inferior vena cava and often results in a “uttering” partial collapse of the lower lobe.83 A pneumothorax results in
loss of a nding referred to as the lung “sliding sign” which
is a hyperechoic line with to-and-fro movement between
lung and chest wall. A pneumothorax may also result in
an ultrasound nding referred to as a “comet-tail artifact”
which is related to the partially compressed visceral pleura.
Similar to examination of the pericardial sac and heart in the
standard FAST, pleural ultrasound looking for an effusion
83–85
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or pneumothorax can be performed quickly and is highly
accurate.
83–85
An anteroposterior chest x-ray performed with the
patient in the supine or semirecumbent position in the
trauma room remains the standard for diagnosis in trauma
centers that do not use surgeon-performed ultrasound.
Although gross intraparenchymal and pleural abnormalities are readily seen, small pneumothoraces may be missed
with this basic technique. The incidence of missed injuries
can be reduced by performing a posteroanterior chest x-ray
in the upright position or by repeating the lm with the
patient in expiration.
It has long been recognized that a small percentage of
pneumothoraces will be recognized in a delayed fashion
hours after an injury. This fact has led to repeating a chest
x-ray at 3 hours (i.e., “a 3-hour rule”) as there is little risk
of a delayed pneumothorax after this.86 Although much
has been written about the benets of CT scanning in
patients with suspected thoracic trauma, many of the
injuries detected with this sensitive imaging modality do
not require treatment. Examples include incidentally discovered fractured rib(s), asymptomatic pulmonary contusion, and small pneumo- or hemothoraces.87 The major
advantage of chest CT is in the diagnosis of blunt injury
to the thoracic aorta.
NONOPERATIVE MANAGEMENT
Tube Thoracostomy
Adults with a pneumo- or hemothorax who have a systolic
blood pressure of 90 mm Hg or greater are usually treated
with insertion of a 36- or 38-Fr thoracostomy tube. The
chest tube is placed in the ipsilateral midaxillary line in the
4th or 5th intercostal space under sterile conditions and
with local inltrative anesthesia. It has been documented
that 28- to 32-Fr tubes have the same success rates as larger
tubes in treating traumatic pneumo- and hemothoraces.88
More recently, 14-Fr pigtail catheters have been shown to
have reasonable success rates in treating traumatic pneumothoraces.
89,90
The role of prophylactic antibiotics in conjunction with
tube thoracostomy is controversial. If given, a rst-generation cephalosporin is the antibiotic of choice and should
be administered intravenously before the incision to insert
the tube.
6. Open, operative rib xation with metal or absorbable
plates.
91–93
Supportive Care After Pulmonary Contusion
The presence of blood in alveoli and the interstitium of
the lung after penetrating or blunt chest trauma causes a
ventilation/perfusion mismatch and hypoxia. Oxygen by
a nasal cannula or by a close-tting mask with judicious
administration of maintenance uids based on hemodynamic status are the mainstays of treatment in patients
without early onset respiratory failure. Placement of a central venous catheter to measure venous pressure may be
useful in older patients with a pulmonary contusion. Signs
of respiratory failure (e.g., pO2 less than 70 torr on oxygen,
pCO2 greater than 55, respiratory rate of greater than 25,
poor negative inspiratory force, or worsening chest x-ray)
mandate intubation. A signicant pulmonary contusion
can progress in a short period of time to become every bit as
serious as other forms of acute lung injury and adult respiratory distress syndrome (ARDS).
OPERATIVE MANAGEMENT IN THE EMERGENCY
DEPARTMENT AND OPERATIVE ROOM
Indications
The indications for emergent or resuscitative thoracotomy
with or without cross-clamping of the descending thoracic
aorta have been discussed elsewhere in this chapter and are
also provided in Box 16.1 (Fig. 16.20).
Incisions
When there is hemorrhage likely to be from the right pulmonary hilum or lung, the patient is placed in the supine position, and a right anterolateral thoracotomy incision is made
on the inferior edge of the right male nipple. As previously
noted, the right breast of a female is retracted superiorly to
allow for a skin incision at the same level as in the male,
but without damaging the breast. A suspected or conrmed
injury to the tracheobronchial tree at the level of the carina
or right mainstem bronchus is approached through a right
posterolateral thoracotomy at the 4th intercostal space.
When hemorrhage is suspected from the left pulmonary
hilum or lung, the patient is placed with the left chest elevated 30 degrees on a rolled sheet or beanbag. This allows
Analgesia
Pain control following rib fracture(s) is extremely important and allows patients to cough, use an incentive spirometer, and reduce the risk of atelectasis and pneumonia. The
options for local and regional analgesia for patients include
the following:
1. Lidoderm (Lidocaine Patch 5%, Endo Pharmaceuticals,
Malvern, PA)—three 10- × 14-cm patches applied for up
to 12 hours
2. Intercostal nerve block with 3 to 5 mL 0.25% bupivacaine per rib
3. Continuous intercostal nerve block
4. Intrapleural regional analgesia with 20 mL 0.25%
bupivacaine
5. Continuous epidural analgesia
Box 16.1 Indications for Emergency or Urgent
Thoracotomy in Patients With Trauma to the
Lung
n 1200 mL to 1500 mL of blood evacuated through thoracostomy
tube in the first 15 to 30 minutes
n 100 mL of blood per hour evacuated through a thoracostomy
tube after the initial 1000 mL drainage in the first 30 minutes
n Refractory hypotension in the presence of continued evacua-
tion of blood through a thoracostomy tube
n Recent or in-emergency department cardiac arrest after a pen-
etrating wound to the chest, but away from the mediastinum
n Need for reconstruction of the chest wall in the patient with
open pneumothorax
n Massive air leak through the thoracostomy tube (presumptive
evidence of injury to the trachea or the bronchus)
n Retained foreign body (knife near hilum of lobe or lung)
16 • Cardiac, Great Vessel, and Pulmonary Injuries 193
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Box 16.2 Techniques for the General Surgeon
to Control Hemorrhage From a Perforation or
Rupture of the Pulmonary Artery or Lung
Proximal Vascular Control
Intrapericardial clamping of the right or left pulmonary artery
Cross-clamping of the hilum of the lung
Hilar snare
Hilar twist
Control of Hemorrhage From the Lung
Suture pneumonorrhaphy
Stapled-wedge resection
Pulmonotomy (“pulmonary tractotomy”)
Lobectomy
Pneumonectomy (hilum ligated or stapled)
pleural cavity, retracts the lower lobe laterally, divides the
inferior pulmonary ligament, and assumes manual control
Fig. 16.20 Patient with gunshot wound to left midaxillary line (skin clip)
had exsanguinating hemorrhage from perforations to the left lung.
for easier cross-clamping of the descending thoracic aorta
if this should become necessary. The standard anterolateral
thoracotomy incision is then made on the inferior edge of
the male nipple. A suspected or conrmed injury to the left
mainstem bronchus is approached through a left posterolateral thoracotomy at the 5th intercostal space.
of the hilum. The surgeon then places the aortic cross-clamp
across the hilum in whichever direction allows for best
exposure of the injuries.
Hilar Twist. The group at Ben Taub Hospital in Houston
described the “hilar twist” in 2003 as a maneuver to be
considered “when appropriate clamps are lacking or difcult
to place due to exposure or bleeding.”
96,97
This maneuver is
performed after division of the inferior pulmonary ligament
by rotating or twisting the lung and the hilum 180 degrees
to occlude vessels and the mainstem bronchus.
Proximal Vascular Control (Box 16.2)
Intrapericardial Clamping of Pulmonary Artery. An
injury to the pulmonary hilum is highly lethal, and it
is rare for a patient with this type of injury to reach the
trauma center with signs of life. If the hilum adjacent to
the pericardium is injured, it will be necessary to obtain
intrapericardial control of the pulmonary artery. An
anterolateral thoracotomy incision made to expose the
hilum and the lung will need to be extended across the
sternum in a transverse direction to allow for exposure
of the mediastinal and intrapericardial structures. The
intrapericardial right pulmonary artery is exposed by
retracting the superior vena cava to the right and the
ascending thoracic aorta to the left. This vessel passes
transversely at this level and is clamped in the space as
the other vessels are separated. The intrapericardial left
pulmonary artery is exposed by retracting the ascending
thoracic aorta to the right and superiorly. This vessel
passes transversely under the transverse aortic arch and
proximal descending thoracic aorta and is clamped in this
space.
Cross-Clamping of the Hilum of the Lung. Ex sangui na ting hemorrhage from the hilum outside of the pericardial sac
or from the parenchyma is controlled with cross-clamping
of the pulmonary hilum.94 In order to place a DeBakey aortic
clamp across the hilum of the lung in the anteroposterior
direction, the inferior pulmonary ligament must be divided.
Van Natta el al. have described an innovative technique in
which the surgeon grips and manually controls the pulmonary
hilum.95 The left hand is used when a right thoracotomy
is performed, and the right hand is used when a left thoracotomy is performed. An assistant evacuates blood from the
Control of Hemorrhage From the Lung (See Box 16.2)
Suture Pneumonorrhaphy. With wounds or lacerations
on the periphery of a lobe, hemorrhage and air leaks can
be controlled by placing a continuous 2-0 or 0 absorbable
suture through the edges of the defect. If hemorrhage
is excessive and the defect on the edge is long, a DeBakey
aortic clamp can be placed underneath the laceration, and
the continuous suture row can be placed over the clamp.
Stapled Wedge Resection. Larger defects involving the
outer half of a pulmonary lobe may be excised using one
of the standard staplers (4.8-mm staples) up to 90 mm in
length. The pulmonary or lobar hilum is clamped in these
cases if a double lumen endotracheal tube has not been
placed. Standard lung clamps are then used to elevate the
injured segment into good view and an appropriate length
staple row is placed through normal parenchyma. It is
possible to perform a partial lobectomy with two staple lines
at right angles to one another. This creates an oddly shaped,
but hemostatic and functional, remainder of a lobe. Deep
absorbable sutures are placed around areas of the staple
row when bleeding occurs. The major disadvantage of large
staple resections is that a bleeding intraparenchymal vessel
may not be ligated or excised. Continued bleeding from
such a vessel may enter the tracheobronchial tree through
an adjacent bronchial injury and lead to intraoperative
aspiration and asphyxia.
Pulmonotomy (Pulmonary Tractotomy) (Fig. 16.21).
Pulmonotomy or pulmonary tractotomy was derived from
the technique of hepatotomy and selective ligation of vessels
following severe hepatic trauma. With deep lobar missile
tracks or lacerations and signicant bleeding, neither suture
pneumonorrhaphy nor stapled wedge resection is appropriate.
194 SECTION 4 • The Management of Vascular Trauma
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Properly performed, pulmonotomy with selective vascular
ligation will control parenchymal hemorrhage without the
need for lobectomy.
79,82,98,99
With exsanguinating hemorrhage from vessels in the deep
parenchyma after a gunshot or stab wound, a hilar clamp is
applied after division of the inferior pulmonary ligament. A
linear stapling device is then passed through the entrance
and exit wounds in the same lobe, and the outer pulmonary
parenchyma is divided. When hemorrhage is coming from
one gunshot or stab wound in a lobe, a nger or clamp is
placed into the hole to determine the direction of the track.
The linear stapler can be used again to open the parenchyma,
or two DeBakey aortic clamps can be placed in apposition and
the parenchyma between them divided with a scalpel or with
electrocautery. Injured vessels in the now-open track are
ligated or repaired with 3-0 or 4-0 polypropylene suture.
After bleeding has been controlled, edema of the parenchyma almost always precludes closing the pulmonotomy
site. Individual suture ligation is used to control remaining vessels under the rows of staples. If DeBakey clamps
were used to divide the parenchyma, 3-0 or 4-0 absorbable
or polypropylene suture is placed in a continuous basting
stitch under each clamp. After a clamp is removed, the same
continuous suture is returned to the starting point in an
over-and-over fashion and tied to the original suture.
Lobectomy. Anatomic lobectomy is indicated when there
is signicant injury to the vessels or bronchus in the hilum
of the lobe, injury to greater than 75% of the parenchyma
Left lung
of the lobe (i.e., shotgun wound), devascularization of
the lobe, or a lobar hematoma causing life-threatening
ventilation–perfusion mismatch.
100
Prior to performing
lobectomy, the residual tissue in the ssures around the
injured lobe is divided with a linear stapling device or
divided between clamps and then sutured. A DeBakey
aortic clamp is then placed across the entire lobe just
outside the hilum to stop bleeding or respiratory expansion
during lobectomy. The pleura over the hilar structures is
divided, and the lobar artery and proximal branches are
divided between 2-0 silk ties. The lobar vein and branches
are divided in a similar manner. Minimal skeletonization
of the lobar bronchus is performed to preserve bronchial
blood ow before stapling and dividing the bronchus. An
airtight staple line is veried by lling the pleural cavity
with normal saline and having the anesthesiologist hand
bag the patient. A three-sided pleural ap is elevated off of
the paravertebral area and sewn over the bronchial stump
with 3-0 absorbable sutures. Prior to insertion of two
36-Fr thoracostomy tubes, the remaining lobe or lobes are
hyperinated. This maneuver will conrm that no damage
has occurred to other bronchi during the lobectomy and
that torsion of the remaining lobe or lobes is not present
and is unlikely to occur in the postoperative period. If there
is a risk of torsion, either suturing or stapling the lobes
together or suturing the lobe to the mediastinal pleura at
another point is performed.
Pneumonectomy. A pneumonectomy is only indicated
when there is a signicant penetrating wound or shearing
injury to the vessels or bronchus in the hilum of the lung or a
major injury encompassing more than 75% of all lobes.
101–103
As most patients requiring a trauma pneumonectomy are
in extremis, the “simultaneously stapled pneumonectomy”
has been suggested as an alternate approach to formal
hilar dissection and ligation/stapling.
101
First described in
1995, the technique is to place a 55- or 90-mm stapler
across all hilar structures simultaneously for temporary
vascular control or red for permanent control of the
hilum. Reexploration for possible further stapling of a long
bronchial stump and coverage with a vascularized tissue
pedicle were recommended as well.
101
Right heart failure is
common in patients who survive trauma pneumonectomy,
and postoperative management is quite intensive, often
including infusion of nitric oxide and/or inotropic support.
104
Fig. 16.21 Linear stapling device passed through gunshot entrance
and exit sites to divide parenchyma (pulmonotomy or pulmonary tractotomy) and to expose bleeding vessels. (With permission from Asensio
JA, Demetriades D, Berne JD, et al. Stapled pulmonary tractotomy: a rapid
way to control hemorrhage in penetrating pulmonary injuries. J Am Coll
Surg. 1997;185:486–487.)
Stapler
Thoracic Damage Control
Originally described for patients with penetrating wounds
of the abdomen, damage control operative principles have
now been described for patients with injuries to the neck,
chest, extremities, vessels, and bones.
are now applied to patients undergoing emergency operations on the general surgery and obstetrics services as well
as those undergoing emergency procedures in the interventional radiology suite. The most fundamental principle of
damage control surgery is that the patient with profound
hypothermia, a signicant metabolic acidosis, or a marked
coagulopathy should have a limited rst operation or procedure to control bleeding and contamination. For injuries to
the heart, great vessels, or lungs, many of the techniques
described in this chapter t the denition of thoracic damage
105
Similar principles
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