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E. Degiannis et al.
Fig. 38.5 Resection and anastomosis of gunshot injury to the proximal
intrathoracic trachea. Operative approach via a low transverse cervical
incision with hyperextension of the neck in a young patient. (a) Gunshot
38.4 Operation
injury of the trachea (b) resection of the injured part of the trachea (c)
suturing of the trachea (d) operative specimen of resected part of the
trachea
the scapula out of the site of the incision. Secure the arm in
this position to the ether screen or to an armrest. The antecu-
Proper positioning of the patient for posterolateral thoracotomy will facilitate easy access to the injury (Fig.38.6). Start
with placing the patient in a full lateral position. Extend the
dependent arm at a right angle to the trunk, forearm/hand
facing upwards. Fix the dependent leg at a right angle and
keep the upper leg straight. Place a pillow between the two
legs and another pillow beneath the chest, perpendicular to
the patient. The latter will facilitate the thoracotomy by widening the intercostal spaces at the operation site. At this point
attention should be paid to the rm xation of the patient, to
avoid undesirable body movements. Placement of a sandbag
anteriorly and posteriorly together with the application of a
strap over the padded superior anterior iliac crest will do the
trick. Finally, position the upper arm by extending it in a
cephalad direction as high as possible resulting in rotation of
bital fossa over the armrest must be padded, because of the
risk of postoperative ulnar nerve paresis. The arterial line
should be inserted at the radial artery of this forearm giving
the anaesthetist easy access to do blood gases during the
operation. Attach the diathermy pad to the upper thigh.
Stand behind the patient and start the incision from just
lateral to the sternocostal junction to 1cm below the tip of
the scapula, then curving upwards in the midline between the
vertebral column and the medial margin of the scapula,
almost reaching its upper border.
The wound is deepened by using diathermy coagulation
current and dividing the muscles individually. With the incision deepened down to the rib cage the individual ribs must
be identied so that the thoracic cavity is entered through the
appropriate intercostal space. To do this elevate the scapula
1
2
3
5
4
38 Penetrating Trauma totheMediastinal Trachea andMain Bronchi
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Fig. 38.6 Positioning of a
patient for posterolateral
thoracotomy. (1) Strap over
hips to hold patient to the
table (2) xation of position
by sandbag (3) rolled towel
beneath the chest (4) pillow
under head (5) medial border
of the scapula
331
with a scapula retractor and slide your hand in the avascular
space between the scapula and the chest wall as caudally as
possible. Start counting the ribs from above down, beginning
at the second, as the rst is usually impalpable. In the unlikely
situation that this is not the case, you can differentiate
between the rst and second ribs as there is a step between
these two ribs. There is no step present between the second
and third rib. Choose the appropriate intercostal space
depending on the injury. Enter the thoracic cavity by dividing the intercostal muscles at the superior border of the rib.
On visualizing the thoracic wall pleura, inform the anaesthetist to isolate the lung (if the patient has been intubated with
a double-lumen tube). If the patient’s physiological condition allows, gradually spread the ribs with a Finochietto
retractor to avoid iatrogenic fractures. If a fast opening of the
rib case is required and results in rib fractures, special care
should be taken by the surgeon and the assistant to avoid
injury from the rib spikes.
Simple lacerations are related to stab wounds and do not
require debridement. They are repaired by interrupted
absorbable sutures (e.g., 3-0 polyglycolic acid suture, 3-0
polydiaxanone suture) including 2–3 mm of mucosa and
ensuring that the knots are outside, lowering the incidence of
suture line granuloma and late stenosis. If the laceration
involves the rigid portion of the trachea the sutures should be
inserted through the brous tissue, that is between the
C-shaped cartilages (Fig.38.7).
Injuries inicted by bullets can be related to loss of tissue
and require adequate debridement. This, in the majority of
cases, necessitates resection of part of the trachea with endto- end anastomosis.
If resection is required, avoid extensive proximal and distal dissection of the trachea to prevent damage to its blood
supply, that is segmental, as well as injury of the recurrent
laryngeal nerve. While doing the distal resection, insert two
stay sutures at 3 and 9 o’clock below the planned resection
line so that you control the distal tracheal stump and prevent
its retraction deeper into the mediastinum. This can particularly be the case with injuries of the upper thoracic trachea
that were decided to be operated via a low transverse cervical
incision.
On resecting part of the trachea, the anaesthetist and surgeon cooperate closely. The anaesthetist hyperventilates the
patient and pulls the endotracheal tube proximally to the site
of the injury. The surgeon resects the injured part of the trachea and immediately passes another endotracheal tube into
the lumen of the distal tracheal stump for further ventilation
and anaesthesia (Fig. 38.8a, b). If possible, this “distal”
endotracheal tube should be of a slightly smaller size to
make it easier for the surgeon to work when placing the posterior sutures. Start the anastomosis by placing interrupted
sutures on the posterior membranous wall of the trachea and
on completion of this posterior suture line, remove the “distal” endotracheal tube. Then the anaesthetist advances the
original endotracheal tube, which was pulled above the site
of the injury, distally bridging the anterior gap and entering
the distal tracheal stump (Fig.38.8b). The anterior part of the
anastomosis is then completed with interrupted pericartilaginous sutures (Fig. 38.8c). Overall, the type of the
suture and the suturing technique is the one mentioned in the
case of repair of simple lacerations.
If the suture line needs to be reinforced (e.g., penetrating
injury involving both trachea and oesophagus), this should
be done with a patch of the pericardium or a posteriorly
based pedicled intercostal muscle ap. The homogenous
pericardial patch can also be applied to close an isolated
332
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E. Degiannis et al.
Fig. 38.7 (a) Laceration of the right main bronchus due to stab wound. Endotracheal tube can be seen through the bronchial defect. (b) Simple
repair by interrupted absorbable sutures
Fig. 38.8 Stages of resection
and anastomosis of
mediastinal trachea/main
bronchi. The cooperation of
the surgeon and anaesthetists
is of paramount importance.
(a) Tracheal defect after
gunshot injury. (b) left: First
endotracheal tube pulled
proximally to the site of
injury with second one being
introduced into distal tracheal
stump. right: Completion of
posterior suture line. Removal
of distal endotracheal tube
and “original” endotracheal
tube is advanced to enter the
distal tracheal stump. (c)
Completion of anterior part of
anastomosis. (Reprinted with
permission from Springer,
Penetrating Trauma, 2nd ed.
by George C.Velmahos, Elias
Degiannis, Dietrich Doll,
2015)
a
b
c
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333
large defect of the posterior wall otherwise requiring an
extensive resection resulting in excess anastomotic tension.
In these cases, placing a silk suture from the chin to the
manubrium will decrease tension and give the opportunity to
the anastomotic line to “adapt”.
Injury of the carina may require intubation of both right
and left bronchi. Major injuries of the two main bronchi
requiring resection are similarly dealt with while maintaining ventilation by selective intubation of the opposite
bronchus. One lung ventilation can cause hypoxia, due to
the shunting of blood through the unventilated lung.
Should this develop, it is easily overcome by clamping the
pulmonary artery with a vascular clamp. This should be
anticipated by exposing and taping the relevant pulmonary
artery before interruption of the ventilation to the lung in
question.
At the end of the operation, two intercostal drains
should be inserted with an entry point just above the level
of the diaphragm. The one drain should be straight, entering at the anterior axillary line and being positioned anteriorly to the lung with its tip at the apex. The second drain
should be curved, entering the thoracic cavity at the posterior axillary line, with its tip posterior to the costophrenic
angle.
Close the thoracic cage by inserting a gure of eight high
tensile strength sutures (e.g., 1-0 polyglycolic acid suture),
passing from the inferior border of the lower rib to the superior border of the upper rib.
Remove the rolled towel from below the chest, approximate the 2 ribs with a rib approximator and tie the sutures.
The rest of the incision is closed in layers.
The endotracheal tube should be removed as soon as the
patient can take satisfactory spontaneous respirations.
Important Points
• Gunshot wounds to the mediastinal trachea are related to
the high incidence of concomitant injuries to other mediastinal structures.
• Irrespective of the CT ndings a bronchoscopy should be
undertaken to conrm or exclude the radiological
diagnosis.
• The standard operative approach is via a posterolateral
thoracotomy.
• In young people hyperextension of the neck can bring up
half of the intrathoracic trachea into the neck. Therefore,
an isolated injury of the upper mediastinal trachea can be
dealt with via a low transverse cervical incision.
• The steps of the repair necessitate close cooperation
between the anaesthetist and the surgeon.
• Always fashion a mucosa-to-mucosa repair with absorbable sutures ensuring that the knots are outside.
Suggested Reading
Baisi A, Nosotti M, Ciof U, etal. Diagnosis of complete mainstem
bronchus avulsion in 3-dimensional spiral CT scan of the chest.
Minerva Chir. 2003;58:587–9.
Hugh J, Milliken J, Chen JC.Management of tracheobronchial injuries
following blunt and penetrating trauma. Am Surg. 1997;63:896–9.
Jennings VA, Doll D, Degiannis E. Non operative management of
gunshot wounds to the cervical trachea with signicant tissue loss
and 3D tracheography as a diagnostic tool: 2 case reports. (Case
Report). Wehrmed Monatsschrift. 2017;61(9–10):240–4.
Palade E, Passlick B.Surgery of traumatic tracheal and tracheobron-
chial injuries. Chirurg. 2011;82:141–7.
Zhao Z, Zhang T, Yin X, etal. Update on the diagnosis and treatment of
tracheal and bronchial injury. J Thorac Dis. 2017;9:56–9.
Operative Management ofPulmonary
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Injuries
KatherineR.Iverson andMarcde Moya
39
39.1 Background
Thoracic injuries account for approximately 30–40% of all
traumatic injuries, contributing to over one-quarter of traumatic deaths. While blunt thoracic trauma is much more
common than penetrating injuries, the need for surgical
intervention for blunt mechanisms is much lower. Less than
10% of blunt injuries will require surgery, compared to an
operative rate of 15–30% in penetrating injuries. The majority of thoracic injuries requiring intervention can be managed with tube thoracostomy for pathology such as
hemothorax and/or pneumothorax without the need for more
invasive procedures. However, the indications for operative
intervention broadly include severe or ongoing hemorrhage,
inadequately drained hemorrhage (such as retained hemothorax), or concern for major cardiac or pulmonary/tracheobronchial injury. Penetrating mechanisms requiring surgical
treatment include gunshot wounds which represent the
majority of these cases, followed by stab wounds, and then
impalements.
Pulmonary injuries, involving the lung parenchyma, are
most commonly managed nonoperatively. This is especially
true in the case of pulmonary contusions, the most common
injury from blunt thoracic trauma. However, in patients
undergoing thoracotomy, the incidence of lung injuries
found from a penetrating mechanism ranges from 30% to
85%. Further, the incidence of minor or major lung resection
at the time of thoracotomy from all injury mechanisms is
estimated to be 20–30%. In this chapter, we will discuss the
operative management of pulmonary injuries and intrathoracic vascular injuries focusing on open thoracotomy.
K. R. Iverson · M. de Moya (*)
Division of Trauma, Acute Care Surgery, Department of Surgery,
Medical College of Wisconsin, Milwaukee, WI, USA
e-mail: kiverson@mcw.edu; mdemoya@mcw.edu
39.2 Positioning andEquipment
The patient should be placed supine on the operating room
table with both arms extended perpendicularly. The patient
should be prepped from the chin to the knees to allow for
sternotomy and saphenous vein grafts in the bilateral lower
extremities if indicated. Essential equipment includes a
Finochietto retractor or rib spreader, a sternal saw, Lebsche
knife, lung (Duval) clamps, large vascular clamps preferably
curved Crawford clamps, and linear cutting staplers (laparoscopic staplers are helpful because of the articulation they
allow). A dual-lumen tube or bronchial blocker is often
needed for lung isolation.
39.3 Incision/Approach
A thoracotomy in the trauma patient is typically performed
for hemodynamic instability or uncontrolled thoracic hemorrhage after tube thoracostomy while maintaining access to
the abdomen for potential operative intervention there. For
this reason, the typical approach is through an anterolateral
thoracotomy on the left for cardiac arrest, or the affected side
in the case of hemorrhage. This is performed sharply through
the fourth intercostal space found at the inframammary fold
or nipple line externally. The incision extends from the sternum medially to the latissimus dorsi laterally. Intercostal
muscles and parietal pleura are divided with Mayo scissors
sharply and a Finochietto rib spreader is placed for exposure.
Attention should be paid to make an acutely curved incision
following the superior border of the rib to avoid transection
of the costal cartilage medially and the intercostal neurovascular bundle inferior to the rib. In cases of bilateral thoracic
hemorrhage, the incision can be extended to the alternate
side with the use of the Lebschke knife or other bone-cutting
device to divide the sternum and expose the contralateral
chest cavity through a clamshell thoracotomy. Care must be
taken to identify the transected internal mammary arteries
after this incision prior to closure.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
E. Degiannis et al. (eds.), Penetrating Trauma, https://doi.org/10.1007/978-3-031-47006-6_39
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In cases of pulmonary injury, the thoracotomy is the preferred approach, however, alternate incisions may be considered in the hemodynamically stable patient, based on the
suspicion of other injuries. A sternotomy is the incision of
choice for patients with possible concurrent great vessel or
cardiac injury, with penetrating injuries medial to the midclavicular line. A left posterolateral thoracotomy is the incision of choice for descending thoracic aortic injuries in a
stable patient. The aortic arch and proximal left subclavian
vessels can also be reached from a high approach on the left.
Aerodigestive injuries including the thoracic esophagus and
distal tracheal to bilateral mainstem bronchi are best
approached through a right posterolateral thoracotomy.
*Key Point: For an anterolateral thoracotomy, attention
should be paid to make an acutely curved incision follow-
ing the superior border of the rib to avoid transection of
costal cartilage medially and the intercostal neurovascular
bundle inferior to the rib.
39.4 Pulmonary Injuries
Penetrating pulmonary injuries are most commonly identied during a thoracotomy performed for the indication of
hemorrhage or pneumothorax not adequately treated with
tube thoracostomy. Accordingly, the procedure of choice is
that which controls the bleeding or air leak with the least
impact on the lung parenchyma. From least invasive to most
invasive these techniques include suture repair, tractotomy,
non-anatomic or wedge resection, lobectomy, and pneumonectomy. It should be noted that the extent of pulmonary
resection directly correlates to the risk of mortality, with
pneumonectomy leading to mortality in over 50% of patients,
whereas tractotomy is associated with 10–15% mortality.
Supercial and peripherally located pulmonary lacerations can be repaired with 3-0 or 4-0 polypropylene sutures
in a gure-of-eight or continuous running fashion. For
through-and-through or deeply tracking wounds, a tractotomy should be performed for fear of an uncontrolled tract.
These tracts could lead to bleeding into the airways or a devastating air embolism to the pulmonary venous system. In a
tractotomy, a linear stapler is placed through the tract of the
penetrating injury to divide the overlying parenchyma and
expose the extent of the underlying injury. This is most commonly done with a linear (gastrointestinal anastomosis or
GIA) stapler with 3.5–3.8mm staples (Fig.39.1).
Alternatively if one does not have access to linear staplers
two large curved Crawford vascular clamps or even just two
Kelley clamps can be used to clamp both sides of the tract.
The surgeon then incises the parenchyma between the two
clamps and oversews under each clamp (Fig.39.2b).
K. R. Iverson and M. de Moya
Fig. 39.1 GIA stapling device with one arm through the tract and the
other on the outside of the lung prior to deploying the device
Any signs of bleeding or air leak are then controlled with
the aforementioned suture techniques using an absorbable
suture. The underlying hilar vessels may also be more readily visualized after tractotomy. Care must be taken to ensure
the remaining lung tissue is viable after this approach. For
areas of signicant injury or devascularization near the
periphery of the lung, a non-anatomic or wedge resection
may be required. Similarly, a linear stapler is used to resect
the damaged area of the lung with reinforcing sutures as
needed. The least amount of parenchyma should be resected
to preserve as much viable lung tissue as possible.
A formal lobectomy or pneumonectomy is rarely required
aside from cases with signicant central parenchymal damage or proximal hilar vessel injury not amenable to control
and repair. This should only be performed if the above strategies fail or for the patient in extremis, given the high mortality associated with these approaches. The initial approach
involves mobilization of the lung by dividing the inferior
pulmonary ligament, inferiorly to superiorly, to the level of
the inferior pulmonary vein. For lobectomy, the ssure must
also be separated. The major vessels are then dissected out
starting at the hilum and extending to the lobar vessels. The
relevant lobar vessels, superior and inferior pulmonary veins,
and/or pulmonary arteries are ligated with a thoracoabdominal (TA) stapler (2.5 mm) or suture ligated. Bronchi are
divided transversely with a TA stapler (3.8mm) or clamped
and sutured close with 4-0 polyester interrupted sutures.
Stapled bronchial stumps should be reinforced with suture
and muscle ap coverage when feasible and an air leak test
should be performed. For a right pneumonectomy, the azygos vein should be identied. For a left pneumonectomy,
care is taken to identify and preserve the phrenic, vagus, and
left recurrent laryngeal nerves. Single lung ventilation can be
achieved by advancing a single-lumen endotracheal tube into
ab
39 Operative Management ofPulmonary Injuries
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Fig. 39.2 Tractotomy with clamp technique; (a) placement of clamps with one arm of the clamp jaw in the tract and the other on the outside with
a second clamp placed next to it; (b) divided lung parenchyma that will require suturing with an absorbable suture prior to removing clamps
337
the left bronchus or using an endobronchial blocker on the
left for right lung ventilation, as adjunctive strategies to a
double-lumen tube.
distal control may require identication of its branching
from the superior vena cava. Once identied, this vessel can
be clamped and suture ligated.
When a penetrating hilar injury is identied, rapid proxi-
*Key Point: A tractotomy or wedge resection with a linear
cutting stapler is the most useful tool for hemorrhage or
air leak control from pulmonary parenchymal injuries.
*Key Point: For pulmonary injuries, the principle of minimal
parenchymal resection is associated with better
outcomes.
mal and distal control is paramount. Hilar control is achieved
through nger occlusion, hilar twist, clamping with a large
angled vascular (Satinsky) clamp, or application of umbilical
tape and Rumel tourniquet. The hilar twist is rarely performed in practice but may be performed for a patient in
extremis when appropriate tools are unavailable. This
involves the rotation of the lung 180 degrees along the main
bronchus to control life-threatening hemorrhage after the
39.5 Intrathoracic Vascular Injuries
inferior pulmonary ligament is divided. The apex of the
upper lobe will now lie along the diaphragm and allow for
In addition to hilar injuries, there are a few other vessels in
the chest which deserve special mention. Intercostal vessels
are challenging to control given their location between two
temporary control until a more permanent solution is available. A penetrating injury to the hilar vessel can be repaired
with a running 5-0 polypropylene suture once identied.
ribs and bidirectional blood supply. Since it is often not feasible to perform a traditional gure-of-eight suture ligation,
alternate techniques are required. One involves placing your
stitch adjacent and parallel to the vessel in the intercostal
muscle for suture ligation. If this is not successful, a large
stitch that encircles the superior rib can be used to compress
the entire neurovascular bundle around the rib. This often
results in neuralgia, and thus this technique should be
reserved for cases where the bleeding is not controlled with
other methods. The internal mammary vessels running paral-
*Key Point: Techniques for intercostal vessel ligation include
suture ligation with the stitch oriented parallelly in the
intercostal muscle or occlusion with a stitch around the
superior rib.
*Key Point: Hilar control is achieved through nger occlu-
sion, hilar twist, clamping with a large angled vascular
(Satinsky) clamp, or application of umbilical tape and
Rumel tourniquet.
lel to the sternum are more easily identied, clamped, and
suture ligated.
39.6 Damage Control
The azygos vein, running vertically along the posterior
thoracic wall and adjacent to the esophagus is another difcult to control injury. The typical approach is through a rightsided thoracotomy, which may require extension across the
sternum to the left side for adequate exposure. Proximal and
Damage control thoracotomy may be indicated in patients
requiring resuscitative thoracotomy for life-threatening hemorrhage control, temporary packing for thoracic bleeding
control, and/or temporary chest closure. Damage control
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K. R. Iverson and M. de Moya
thoracotomy is most commonly performed through a left
anterolateral thoracotomy, especially in the case of hemodynamic instability. This incision can be extended into the right
chest for a clamshell thoracotomy to expose the heart, mediastinum, and right chest as indicated. The decision to pursue
temporary thoracic closure is similar to the factors driving
damage control laparotomy, namely coagulopathy, hypothermia, acidosis, and injury severity. Packing with laparotomy
pads may aid in hemostasis, especially along the chest wall.
However, it is often difcult to pack the chest tightly enough.
If there is a bullet or knife tract that is bleeding one can consider placement of a Foley catheter into the tract and inate
the balloon. This catheter can then be brought out of the
chest and removed the next day. A typical temporary dressing should consist of either a vacuum-assisted device, skinonly closure, or a clear adhesive lm for a seal and chest
tubes in place for drainage.
*Key Point: Damage control thoracotomy and temporary
chest closure are guided by the principles of coagulopa-
thy, hypothermia, acidosis, hemodynamic instability, and
injury severity.
39.7 Conclusion
Operative management of pulmonary injuries is guided by
the principles of expedient vascular control and minimizing
parenchymal resection. The tips and tricks in this section are
meant to optimize surgical success when facing these injuries. Tractotomy and non-anatomic wedge resection should
be utilized to preserve underlying lung tissue. Techniques for
managing specic intra-thoracic vascular injuries have been
described, but the list is by no means exhaustive. Ultimately,
the approach to pulmonary trauma will be guided by the
patient’s clinical status, anticipated injury pattern, and available resources.
Important Points
• For an anterolateral thoracotomy, attention should be paid
to make an acutely curved incision following the superior
border of the rib to avoid transection of costal cartilage
medially and the intercostal neurovascular bundle inferior
to the rib.
• A tractotomy or wedge resection with a linear cutting sta-
pler is the most useful tool for hemorrhage or air leak con-
trol from pulmonary parenchymal injuries.
• For pulmonary injuries, the principle of minimal paren-
chymal resection is associated with better outcomes.
• Techniques for intercostal vessel ligation include suture
ligation with the stitch oriented parallelly in the intercostal
muscle or occlusion with a stitch around the superior rib.
• Hilar control is achieved through nger occlusion, hilar
twist, clamping with a large angled vascular (Satinsky)
clamp, or application of umbilical tape and Rumel
tourniquet.
• Damage control thoracotomy and temporary chest closure are guided by the principles of coagulopathy, hypothermia, acidosis, hemodynamic instability, and injury
severity.
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Operative Management ofDelayed
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Complications ofPulmonary
andPleural Injury
GeorgeV.Oosthuizen, VictorY.Kong, andOferMerin
40
40.1 Introduction
The incidence of penetrating thoracic trauma varies according to geography and in the United States accounts for up to
10% of all major trauma cases. Although relatively less common than blunt injuries, it is a common preventable cause of
mortality among trauma patients. Most penetrating thoracic
injuries comprise stab wounds and gunshot wounds that are
likely to be encountered at urban trauma centres. The vast
majority of penetrating thoracic injuries can be managed
with a chest tube alone and only 10–15% require emergency
operation. However, a wide variety of complications can
result from penetrating thoracic injuries that can lead to
appreciable morbidity and even mortality.
40.2 Pleural Complications
40.2.1 Retained Hemothorax
40.2.1.1 Background
By denition, a retained hemothorax (RHTX) is said to be
present when the hemothorax remains despite initial evacuation with a chest tube. Although the exact volume pertaining
to this denition varies in the literature, the overall incidence
of RHTX has been reported in up to 20% of cases. RHTX is
signicant as it is also associated with the development of
G. V. Oosthuizen (*)
Department of Surgery, Tygerberg Hospital, Stellenbosch
University, Cape Town, South Africa
Department of Surgery, University of KwaZulu Natal,
Durban, South Africa
V. Y. Kong
Department of Surgery, Auckland City Hospital, University of
Auckland School of Medicine, Auckland, New Zealand
O. Merin
Department of Cardiothoracic Surgery, Shaare Zedek Medical
Center, Hebrew University School of Medicine, Jerusalem, Israel
e-mail: merin@szmc.org.il
other pulmonary and pleural space complications such as
pneumonia, empyema and brothorax. The primary cause of
RHTX is thought to be related to incomplete evacuation of
initial hemothorax via chest tube. Various risk factors have
been identied to be associated with RHTX, which include
initial hemothorax volume on CT, high chest tube output,
duration of chest tube, and total number of chest tubes. A
recent Eastern Association for the Surgery of Trauma (EAST)
multi-institutional trial demonstrated that RHTX was independently associated with a larger hemothorax on presentation, with a 15% increase in risk of developing RHTX for
each additional 100mL of hemothorax on initial CT imaging. Furthermore, unsuccessful treatment was associated
with worse functional outcomes at discharge.
40.2.1.2 Investigations
RHTX is usually suspected when the initial chest tube fails
to evacuate the hemothorax and can be seen on the chest
radiograph (CXR). However, the literature suggests that the
minimum amount of pleural uid required to cause blunting
of the costophrenic angle on erect CXR is 300mL.In supine
patients, this can take up to 1000mL. Although ultrasound
remains a useful adjunct, cross-sectional imaging with CT is
the current standard and can accurately detect RHTX and
other associated complications. While the amount of uid
that constitutes RHTX remains debatable, quantifying the
amount on CT is equally controversial. The most common
method of estimating RHTX volume on CT was proposed by
Mergo etal., which is derived from the measurement of the
greatest depth of hemothorax from the chest wall, craniocaudal length, number and thickness of the CT slides. A useful
screening test to determine whether RHTX may be clotted or
loculated (and therefore not amenable to drainage by repeat
chest tube) is a lateral decubitus CXR.The patient is placed
in the lateral position for 3–5min, after which an anteroposterior shoot-through is performed. The lateral decubitus lm
is compared with the upright, and if run-off of the pleural
collection has occurred after the change in body position, the
pleural contents are deemed to be liquid, and likely to be
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
E. Degiannis et al. (eds.), Penetrating Trauma, https://doi.org/10.1007/978-3-031-47006-6_40
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G. V. Oosthuizen et al.
evacuated by a repeat chest tube. If no run-off is noted, the
collection is deemed to be clotted or loculated and repeat
chest tube is not likely to succeed. Chest CT may be helpful
to differentiate between consolidation and collection, and to
plan further management.
40.2.1.3 Management
In practice, various management strategies have been proposed and the exact approach varies depending on the
resources of the individual institution. The options include
observation, repeat chest tube, intrapleural lytic therapy,
video- assisted thoracoscopic surgery (VATS), and
thoracotomy.
Observation
Historical series on experimental observation suggested that
pleural blood can be absorbed spontaneously and most suggest that a small RHTX (dened as <300 mL) may be
observed. The natural history of these patients with small
RHTX under observation is not well dened but it has been
suggested that it may be successful in over 80% of cases.
Repeat Chest Tube
Repeating chest tubes in an attempt to evacuate RHTX is
logical and a technically simple procedure. This can be
accomplished by either open surgical technique or radiological guidance. This offers an advantage for patients with signicant co-morbidities in which major operative options are
best avoided. In a landmark AAST trial, a second chest tube
was successful in 36% of cases, while success rate with
radiologically guided drainage procedure was 59%. However,
up to 25% of all RHTX in their study required at least two
procedures to successfully manage the RHTX.As a separate
caveat, there is evidence to suggest that the risk of developing empyema increases with each subsequent insertion of
chest tube and increases signicantly beyond the second
attempt. Clotted or loculated RHTX and empyema are generally not amenable to evacuation by chest tube.
Intrapleural Lytic Therapy
Fibrinolytic therapy with a pharmacological agent such as
alteplase has demonstrated positive results. It relies on plasminogen activation that triggers brinolysis and thereby
allowing dissolution and evacuation of RHTX.Data from the
abovementioned AAST trial on patients who underwent
intrapleural lytic therapy as the initial treatment showed that
over two-thirds subsequently still required a second procedure to manage the RHTX.Other studies have demonstrated
better efcacy. A systematic review has suggested the advantage of allowing patients to avoid surgery in over 80% of
cases. Studies comparing intrapleural lytic therapy to evacuation via video-assisted thoracoscopic surgery have also
been inconsistent in demonstrating superiority. To date, the
exact case selection remains controversial but intrapleural
lytic therapy may likely be benecial in poor surgical
candidates.
Video Assisted Thoracoscopy (VATS)
VATS has increasingly gained popularity in the management
of RHTX. Early studies showed benet for VATS when
employed following the failure of a repeat chest tube or when
a large volume (>900mL) of RHTX is present. VATS is technically simple and is especially useful in managing loculated
RHTX. The optimal timing of VATS has yet to be determined. Although the correlation between the timing of VATS
and the success rate has not been entirely agreed upon,
emerging evidence is in support of early VATS and is associated with reduced length of hospital stay and reduction in the
need for thoracotomy.
Thoracotomy
Historically this was the default operation which has now
been replaced by VATS.This is usually reserved for cases in
which empyema has become advanced or in which other
options have been unsuccessful.
40.2.2 Empyema
40.2.2.1 Background
Empyema is dened as pus in the pleural space and commonly results from pleural space infection in the setting of
retained hemothorax or pneumonia. It is important to note
that the chest tube procedure itself can potentially introduce
infection into the pleural space and the rate of empyema following thoracic trauma has been reported to range from 3%
to 30%. Prophylactic antibiotics for chest tube insertion have
been a subject of controversy for many years. A recent systematic review has shown that prophylactic antibiotic administration was associated with a reduced risk of empyema and
pneumonia. The natural history of empyema is well recognised and is classically described in three stages, namely the
exudative, brinopurulent, and organising stages.
40.2.2.2 Investigations
Early cross-sectional imaging with CT will allow the characterisation and extent of the empyema to be determined.
40.2.2.3 Management
Broad-spectrum antibiotics and guidance by bacterial culture are important components of management. A prolonged
course of antibiotics is often required. However, the principal concept is that empyema should be viewed in similar
light as an abscess, meaning it should be drained. In the exudative phase, empyema may be drainable via chest drain. In
the brinopurulent phase, loculations and a brinous cap-
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