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https://t.me/med1917
Thoracic trauma
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KENNETH L. MATTOX, MD
Professor & Vice Chair, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
JON-CECIL M. WALKES, MD
Cardiothoracic Resident, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
2
HISTORY
For all countries of the world, throughout history, trauma is
the leading cause of premature years of life lost, accounting
for more years of life lost than the next three causes of death
(cancer, cardiovascular disease, infectious diseases) combined. Thoracic trauma is responsible for up to 25% of the
immediate deaths from trauma and is either responsible or
contributes to an additional 25% of delayed trauma deaths.
Among the trauma patients who die after reaching a health
care facility, up to 33% of these deaths are preventable with
appropriate systems applications, rapid transport, early diagnosis, appropriate therapy, expeditious indicated operation,
and applications of surgical critical care principles postoperatively. A variety of thoracic operations are performed for specific conditions or injuries, and this chapter will focus on
representative thoracic trauma operations. Although sporadic references to isolated injuries are made throughout history, the operations for thoracic trauma are a function of the
twentieth century and principally the last half of the twentieth
century.
PRINCIPLES AND JUSTIFICATION
Up to 80% of patients with thoracic trauma do not require a
formal operation and are managed by observation, tube thoracostomy, and/or pain control. The most common operations following thoracic trauma are tube thoracostomy and
exploratory thoracotomy. Indications for an operation for
thoracic trauma are relatively well defined (Tables 2.1–2.3).
Several historical thoracic trauma operations require careful
justification prior to application. These procedures include
subxyphoid pericardiotomy, thoracic exploration for simple
mediastinal traverse, and “book” or “trapdoor” thoracotomy.
During the last decade of the twentieth century, advances in
imaging, thoracoscopy, and endovascular therapies rapidly
began to alter both the evaluation and treatment of thoracic
trauma. In addition, advances in surgical critical care, anesthesia, and drugs altered the preoperative and postoperative
care of patients with thoracic injury. As an example, bullet
embolism and transthoracic injection of industrial solvents
are no longer absolute indications for thoracotomy
Table 2.1 Indications for acute thoracotomy
Hemopericardium
Traumatic thoracotomy
Continuing hemothorax
Radiological evidence of thoracic great vessel injury
Esophageal injury
Massive air leak
Major bronchus injury
Witnessed traumatic arrest
Table 2.2 Considerations for further evaluation following thoracic
trauma
Chest wall penetration of industrial solvents
Bullet embolism
Systemic air embolism
Mediastinal traverse
Table 2.3 Indications for chronic thoracotomy
Retained clotted hemothorax
Traumatic lung abscess
Delayed discovery of pseudoaneurysm
Traumatic cardiac valve or septal injury
Nonclosure of a chylous fistula
Biliary–bronchial fistula
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PREOPERATIVE ASSESSMENT AND
PREPARATION
Evaluation of any trauma patient involves prehospital assessment and transport, primary and secondary surveys in the
emergency center, including trauma and thoracic surgeon
evaluation and decision-making with regard to operation and
continuing reassessment. To avoid missing an injury, a tertiary survey (repeat and re-repeat of the secondary survey) is
recommended by many surgeons. The importance of injury
background history, past medical history, and physical examination cannot be overemphasized.
Laboratory evaluation
For any trauma patient, minimum laboratory studies are
required, such as dipstick urinalysis, hematocrit and, possibly, arterial blood gas evaluation. Should an operation be
anticipated, type and cross match is considered. If angiography is anticipated, blood urea nitrogen (BUN) and creatinine
are useful to the angiographer. Many of the routinely ordered
biochemical tests do not alter the surgical decision-making,
and include tests such drug screening, electrolytes, clotting
studies, and liver function tests.
Routine and special imaging
The single most helpful evaluation of a patient with thoracic
trauma is routine supine chest X-ray. A “funny looking mediastinum” suggests numerous signs that have been described
and indicates a need for additional tests. Up to 5% of patients
later found to have an injured aorta do not have any of these
signs, nor a mediastinal hematoma on chest CT scanning.
Hemothorax, pneumothorax, pneumomediastinum, bullet
tract trajectories, mediastinal hematomas, missile fragments,
broken bones, subcutaneous emphysema, thoracic outlet
hematomas, and many other conditions can be readily diagnosed on this initial X-ray, and follow-up routine chest Xrays. Technological advances in imaging are randomly used
by evaluating physicians, often without eliciting any additional or new information other than that already demonstrated on initial chest X-ray. These newer tests include
computed tomography (CT), ultrasonography, magnetic resonance imaging (MRI), magnetic resonance angiography
(MRA), and echocardiography, especially transesophageal
echocardiography. Some digitizing machines provide 3-D
reconstructed structures.
Spiral computed tomography
For a number of reasons, CT has been used with increased
frequency for patients with thoracic trauma. Specifically,
many emergency center physicians are using CT to look for
mediastinal hematomas in patients with blunt thoracic
injuries. Application of CT in this instance consumes both
financial and personnel resources for a test that rarely alters
the necessity for thoracic arteriography. CT often fails to
demonstrate many of the more than 12 common congenital
anatomical variants, which may be present in this subset of
patients. CT scanning is critical to the evaluation of thoracic
trauma patients with delayed or infectious pulmonary complications. The technology of enhanced CT is ever changing.
New technology allowing for 3-D reconstruction of vascular
structures is impressive, but often confusing. Many radiologists are reporting new spiral CT findings for which no clear
understanding of the anatomical, histopathological, or physiological significance exists. It is important that any surgeon
making a surgical decision fully understands the variances of
emerging technology and is assured of specific injury patterns
prior to an operation.
Focused abdominal sonogram for trauma (FAST)
The use of ultrasound imaging of the heart allows the surgeon
to diagnose hemopericardium, oftentimes before it becomes
clinically evident. As such, ultrasound is an invaluable screening tool in patients with suspected hemopericardium.
Typically, the surgeon will obtain a subxyphoid or subcostal
view of the heart and pericardial space coupled with a threeview ultrasonogram of the abdomen. The main limitation of
the FAST exam is the learning curve of the examiner. Once
mastered, one may expect a specificity of 95%. The most utilitarian application of FAST is in the patient with a hemopericardium.
Magnetic resonance imaging (MRI)/magnetic
resonance angiography (MRA)
MRI and MRA are rarely used in the evaluation of thoracic
trauma. Some spinal cord injuries require MRI, and MRA
might be indicated for evaluation of thoracic outlet vascular
injury in patients with dye allergies.
Arteriography
Arteriography is the gold standard for diagnosis of vascular
injury. Even with a transesophageal echocardiography (TEE)
or enhanced spiral CT scan demonstrating hemomediastinum, most surgeons will not operate on a thoracic vascular injury until the arteriogram has demonstrated the specific
anatomy and injury location. For blunt injury to the thoracic
aorta, aortography should follow a suspicious initial plain
chest X-ray. For suspected penetrating injury to the aorta,
aortography may not demonstrate the injury due to the dense
dye column. For suspected thoracic outlet vascular injury,
arteriography in the stable patient is essential in selecting the
incision and planning treatment.
Operation 17
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Transesophageal echocardiography (TEE)
TEE has been used electively by cardiac surgeons to assess the
adequacy of cardiac septal and valvular repairs. TEE may be
used to diagnose such septal and valvular injury following
trauma. TEE has been used in some trauma centers to
demonstrate an aortic injury. Like spiral CT, TEE is inconsistent in diagnosing with accuracy aortic injuries outside the
usual location of the proximal descending thoracic aorta. At
times, the TEE is also extremely sensitive, demonstrating
shadows also shown with echo findings at thoractomy.
Esophagoscopy/tracheoscopy/bronchoscopy
Endoscopy is often used in penetrating thoracic trauma. In
penetrating injuries, the blast effects often caused by missiles
are frequently associated with extensive tissue destruction
surrounding the area of penetration. Endoscopy allows the
trauma surgeon to identify injuries to the aerodigestive tract
and then operatively address such injuries in an appropriate
manner.
ANESTHESIA
subxyphoid cardiac ultrasonography, hemopericardium is
now diagnosed before it becomes clinically evident. As a
result, patients are frequently taken to the operating room for
formal evacuation. However, pericardiocentesis carries the
risk for iatrogenic cardiac injury when performed by an inexperienced individual.
SUBXYPHOID PERICARDIOTOMY
With the advent of the FAST examination, subxyphoid pericardiotomy has virtually no indications. On rare occasions,
when abdominal exploration reveals no explanation for continuing hypotension, a transabdominal pericardiotomy
might be considered.
ENDOVASCULAR RECONSTRUCTION
Increasingly, transvascular stenting, including stented grafts,
is being used to treat thoracic vascular injury, including subclavian, innominate, and even descending thoracic injury,
both blunt and penetrating. For thoracic outlet vascular
injury, some such treatment is being accomplished at the
time of initial diagnostic arteriography. However, most
endovascular treatment is still being performed under
research protocols.
Most trauma centers require a board certified anesthesiologist to be on duty for trauma cases needing an operation. This
requirement is especially important for a patient needing a
thoracic operation. Often, special airway tubes, such as double lumen ventilatory tubes (Robertshaw and Carlin) are
requested. If airway reconstruction is necessary, use of anode
tubes might be necessary. By far the most important elements
for successful management of the trauma patient is the need
for constant communication between the anesthesiologist
and the surgeon. The equipment is especially important with
regard to blood pressure levels, crystalloid fluid management,
use of paralytics, and pain control.
OPERATION
“Minor procedures”
TUBE THORACOSTOMY
Tube thoracostomy in thoracic trauma patients is a fundamental procedure and essential skill in the surgeon’s armamentarium. Tube thoracostomies are used to evacuate air or
fluid from the chest. They may be lifesaving in the case of the
tension pneumothorax. They effectively evacuate blood and
provide a means of monitoring blood loss, thereby aiding in
the decision for formal thoracotomy (see Chapter 12).
PERICARDIOCENTESIS
Pericardiocentesis has traditionally been used in patients
suffering from cardiac tamponade. With the advent of
“Major” exploratory procedures
POSITIONING
Supine and lateral decubitus positions are essentially the only
ones used in thoracic trauma. Oblique positions often compromise exposure and repair.
INCISIONS
The utility incision for thoracic trauma is an anterolateral thoracotomy, usually through the fourth or fifth interspace.
Occasionally, a bilateral transternal anterolateral thoracotomy
is required, taking care to ligate the transected internal mammary arteries. With a transternal thoracotomy, the incision is
curved upward exposing a sufficient amount of sternum for
good closure. A median sternotomy should be reserved for
stab wounds between the nipples and for suspected ascending
aorta and thoracic outlet injury. Posterolateral thoracotomy is
used for injury to the lung, esophagus, descending aorta, azygous vein, and thoracic duct injury.
EMERGENCY CENTER (RESUSCITATIVE) THORACOTOMY
Indications for emergency center thoracotomy have been
narrowed over recent years. Numerous studies have demonstrated that the majority of unintubated patients requiring
prehospital external cardiac massage for 4 minutes die, while
the majority of intubated patients die if administered prehospital cardiopulmonary resuscitation for greater than 10 minutes. Ideally, a patient requiring resuscitative thoracotomy
has been intubated by prehospital personnel.
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For emergency thoracotomy the patient should be placed
1
supine and the incision drawn in an inframammary location at the level of the left fifth interspace. In women, the
breast must be retracted cephalad to open up the interspace.
The intercostal muscles are divided with Mayo scissors,
2
and the interspace opened using a standard rib retractor
with ratchets away from the sternum.
1
2
Scissors are used to open the pericardium anterior to the
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3
phrenic nerve.
Operation 19
3
4
Blood clots are removed, and bleeding is controlled with
4
direct digital pressure. The lung is retracted anteriorly,
and the descending thoracic aorta is occluded with a large
vascular clamp. In a nonbeating heart with penetrating
injury, cardiorrhaphy is accomplished prior to defibrillation.
When the heart is distended, inflow occlusion is accomplished, and the heart is compressed to facilitate cardiorrhaphy.
For injuries of the right atrial appendage, a curved vascular
clamp may be applied to control hemorrhage, and the defect
is closed using a running 4-0 polypropylene suture.
CARDIORRHAPHY
Whether part of an emergency center (resuscitative) or operating room thoracotomy, cardiorrhaphy is performed in the
same manner. Cardiorrhaphy is required more often for penetrating wounds. In the beating heart, cardiorrhaphy is
delayed until other aspects of a resuscitation have been accomplished, such as cross clamping the aorta, securing an airway,
and assuring vascular access. Intermittent cardiac compressions assure forward aortic blood flow during this process.
Temporary control of cardiac hemorrhage may be accomplished using standard or extra wide skin stapling devices.
Glove perforation may be as high as 80% in urgent post-traumatic cardiorrhaphy.
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Definitive control and repair of cardiac wounds is
5
accomplished with 3-0 or 4-0 polypropylene suture.
Injuries to the right and left ventricle are repaired using
horizontal mattress sutures. Vascular clamps are usually not
applied to the ventricles. Some surgeons use Teflon pledgets
to reinforce the repair, although we find that pledgets are not
required. Pledgeted sutures are not routinely used on the left
ventricle. Care is taken while placing horizontal mattress
stitches near the left anterior descending coronary artery (or
other major arteries) so as not to occlude an injured vessel.
Cardiopulmonary bypass for the repair of an injured left
anterior descending coronary artery by aorto-coronary
bypass has been successfully reported in less than six cases.
After cardiorrhaphy is completed, internal cardiac massage
may be re-instituted if necessary. Intracardiac injections may
be accomplished. Cardiac resuscitation is aided by gentle
saline lavage of the heart using fluid warmed to 110°F
(43.5°C).
REPAIR OF INJURY TO THE ASCENDING AORTA
For suspicious injury to the thoracic outlet (blunt or penetrating), a median sternotomy is extended to the neck to
5
assure that control can be achieved. Injuries to the ascending
aorta are more common in penetrating trauma, although the
authors have repaired six blunt ascending aortic injuries in
the past 4 years. Single, anteriorly located wounds might be
repaired by simple aortorrhaphy with 4-0 polypropylene.
Very proximal and posterior ascending aortic injury often
requires the patient to be placed on cardiopulmonary
bypass.
In cases of injury that involve both anterior and posterior
walls of the aorta, a Dacron tube graft is inserted using a running 4-0 polypropylene suture, while on cardiopulmonary
bypass.
REPAIR OF AORTIC ARCH/INNOMINATE ARTERY INJURY
Blunt injury to the aortic arch is often confused with a proximal innominate artery injury, as the intima from the orifice of
the innominate artery rolls up and presents on the arteriogram at 1–3 cm beyond this orifice. Cardiopulmonary
bypass is almost never required for innominate artery reconstruction.
Penetrating injuries to the entirety of the
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6a–c
same manner as are blunt aortic arch and innominate artery
injury. Such injuries are approached through a median sternotomy with an anterior neck extension. For ease in exposure, the innominate vein might require purposeful division.
Injuries are reconstructed by simple bypass exclusion technique with the appropriately sized knitted Dacron graft
sutured to the ascending aorta in an end-to-side fashion,
prior to the interruption of flow through the innominate
artery. With vascular clamps on either side of the injury, the
distal anastomosis is accomplished without heparinization,
shunts, or hypothermia. When the distal anastomosis is completed, the base of the innominate at the aorta is oversewn.
innominate artery are reconstructed in the
Operation 21
6a
6b
REPAIR OF DESCENDING THORACIC AORTIC INJURY
Within the next 5 years, changing therapy for “stable” proximal descending aortic injuries will shift to endovascular
stented grafts, up to and including acute injury. Increasingly,
“stable” aortic injury will have purposeful delay of reconstruction. Reconstruction is accomplished via a fourth interspace posterolateral thoractomy. After entering the chest, the
6c
initial objective with injury of this location is to gain control
of the thoracic aorta, both distal to the site of hematoma and
at the aortic arch. The transverse aortic arch is exposed and
encircled, using umbilical tapes between the left carotid and
left subclavian arteries. The surgeon may consider any one of
several standard and accepted techniques to address circulation distal to the vascular clamps. Should either active or
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passive shunting (with or without heparinization) be considered, the cannulae are inserted and bypass instituted. Whether
shunting or simple clamp and repair techniques are chosen, the
proximal and distal clamps are applied to the proximal aorta,
left subclavian artery, and distal thoracic aorta. The aorta is
entered at the point of maximum hematoma, and the degree
of injury is assessed. A Dacron interposition graft is required
in more than 85% of the cases. The preferred suture material
for primary or graft interposition is 4-0 polypropylene.
PULMONARY TRACTOTOMY
When a through and through injury to the lung is encountered, uncontrolled bleeding often occurs from both holes.
One option is to perform an anatomical resection, either
lobectomy or pneumonectomy. As these injuries are often
nonanatomical and post-traumatic pneumonectomy is not
well tolerated, pulmonary tractotomy is a recommended
option.
A pulmonary tractotomy is an alternative
7a,b
through the parenchymal defect. The tissue is divided and
then oversewn. However, oversewing entry and exit holes at
the surface of the lung may result in uncontrollable hemoptysis or the development of a large pulmonary hematoma,
which might require a later pneumonectomy.
approach. Two large vascular clamps are passed
7a
7b
The surgeon may place two large vascular clamps or
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8
pulmonary stapling devices through the lung injury,
entering into one of the puncture holes. The entrance and exit
sites are then joined using a knife or scissors.
Operation 23
8
The base of the opened tract is oversewn with 0-
9
polypropylene on a large needle, and the two clamped
sides of the tract are stapled with a GIA stapler or oversewn
with 0-polypropylene suture. 4-0 polypropylene suture is
used to selectively ligate bleeding vessels and control air leaks.
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