|SYMPOSIUM - POLYTRAUMA MANAGEMENT
|Year : 2013 | Volume
| Issue : 1 | Page : 13-16
Damage control in thoracic trauma
Nitin Kumar Kashyap
Department of Trauma & Emergency, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
|Date of Web Publication||23-Sep-2013|
Nitin Kumar Kashyap
D-215, Sector-5, Devendra Nagar, Raipur, Chhattisgarh
Source of Support: None, Conflict of Interest: None
Management of thoracic trauma is an integral part in the decision making process for damage control in a case of polytrauma. Approximately 25% of civilian trauma deaths are caused by thoracic trauma and many of these deaths can be prevented by prompt diagnosis and correct management. The article discusses in brief a protocol for management of polytrauma with special emphasis towards thoracic trauma.
Keywords: Thoracic trauma, Damage control, polytrauma
|How to cite this article:|
Kashyap NK. Damage control in thoracic trauma. J Orthop Traumatol Rehabil 2013;6:13-6
Approximately, one quarter of civilian trauma deaths are caused by thoracic trauma and many of these deaths can be prevented by prompt diagnosis and correct management.  In spite of the high mortality rates, about 90% of patients with life-threatening thoracic injuries can be managed by a simple procedure like drainage of the pleural space by tube thoracostomy. 
When to intervene is a big question for the operating surgeon. Intervention is mainly decided by the patient's physiologic status upon arrival to the casualty. The goal of thoracic damage control is to perform the least definitive repair using the fastest and easiest techniques, to shorten the operative time as much as possible and to overcome the effects of bloody vicious cycle of hypothermia, acidosis and coagulopathy.  Initial assessment and treatment of patients with thoracic trauma consists of the primary survey airway, breathing, circulation (ABC), resuscitation of vital function, detailed secondary survey and definitive care.
There are some injuries that can be temporized and require re-operation once physiologic normality has been achieved. There is little consensus regarding the optimal timing of spinal fracture fixation after blunt trauma. Early fixation is preferred in patient with thoracic spine fractures because it allows earlier mobilization and reduces pulmonary complication and thromboembolic events. Early stabilization of the thoracic spine injuries within 3 days after trauma appears to be favorable. Here, we are discussing a decision-making process for damage control of injuries involved in thoracic trauma. ,
| Damage Control Thoracotomy (DCT)|| |
The word "damage control" has its roots in an incident. USS Cole, a US navy guided-missile destroyer, was attacked by the terrorist organization Al-Qaida in October 12, 2000. The bombing created a 40 Χ 40 feet gash in the ship and it took 3 days to get damage under control. While, talking in terms of damage control in trauma care the patient who requires DCT is the hemodynamically unstable patient with penetrating trauma; with few selected cases of blunt trauma. The primary objectives of DCT are to release cardiac tamponade, control intrathoracic bleeding, control massive air embolism or bronchopleural fistula and to permit open cardiac massage. 
The standard incision for DCT is a left anterolateral thoracotomy. The gaining in access to the chest cavity should not take more than 1-2 min. Incision extends from the left side of sternum curving below the left nipple to the left midaxillary line at fifth intercostals space. The chest wall muscles are divided with a knife quickly down to the level of the intercostal muscles. A Mayo scissors is then used to slide along the pleura and intercostal muscles to the extent of the incision thereby opening the entire chest wall cavity. If additional exposure is required, the sternum can be divided with trauma shears. Division of the sternum results in a transaction of the internal mammary arteries. These will start to bleed once blood pressure is restored and will need clipping and ligation subsequently. A chest wall retractor is placed and opened. The left hand is placed posterolateral to the lung with the palm against the lung parenchyma and compresses the lung tissue anteromedially. A very quick assessment is required now. First move is to visualize and access to the descending thoracic aorta. The mediastinal pleura are divided quickly, but carefully around the aorta and a vascular clamp is placed across it, if required. Look for any tamponade in the same time and cardiac tamponade is released by opening the pericardium. The pericardium is opened longitudinally to avoid damage to the phrenic nerve, which runs along its lateral border. The heart is delivered from its pericardial cavity.
| Operating Room (OR)|| |
In the OR, the patient is placed in the supine position with both upper extremities extended laterally and slightly cephalad. Patient is prepped and draped with betadine solution from the neck to the knees so that the groin is available in the event that the saphenous vein is needed for vascular conduit. Warming blanket should be used for prevention of heat loss. The amount of fluid and blood required for resuscitation is difficult to predict on initial evaluation of the patient. A rough guideline for the total amount of crystalloid volume required in the short term is to replace each 1 ml of blood loss with 3 ml of crystalloid fluid. An arterial line is placed to allow invasive hemodynamic monitoring.
| Cardiac Injury|| |
Many patients of cardiac injuries die before arrival at the hospital. As most of time, these injuries are fatal at the scene. The presence of cardiac tamponade is usually made based on classical diagnostic Beck's triad consist of venous pressure elevation, decline in arterial pressure and muffled heart tones. Diagnostic methods include echocardiogram, focus assessment sonogram in trauma. If we have opened the thorax for emergency purpose, we used to give a nick in the pericardium and look for the tamponade as simply looking the pericardium will not give any idea about tamponade; so, it is better to open the pericardium and be sure to rule out the tamponade if doubt persists. The cardiac defect can be temporized with digital control. Cardiac injuries temporized during the initial damage control can be repaired using 4.0 or 5-0 propylene pledgeted suture. The pericardium or polytetra-fluroethylene (PTFE) pledgets can be used. Injuries that can be repaired with the use of cardiopulmonary bypass include intracardiac lesion such as septal defects and valve injuries. Coronary artery injury can be repaired with off pump bypass grafting. Saphenous vein is the conduit of choice. ,
| Lung Injury|| |
Most cases of hemothorax and pneumothorax (simple or tension) can be diagnosed clinically as well as with the help of chest radiography. We prefer to place Intercoastal drainage (ICD) in sixth intercostals space in midaxillary line for hemothorax and pneumothorax as this is the standard protocol in our institute. A satisfactory chest X-ray film may suggest multiple rib fractures.
The treatments of lung injuries include pneumonorraphy, wedge resection, pulmonary tractotomy, lobectomy and pneumonectomy. Bleeding from the lung or massive air leak can be temporarily controlled by vascular clamp placement around the hilum or by dividing the inferior pulmonary ligament and twisting the lung 180° on its axis. , Pneumonorrhaphy or over sewing of the entrance and exit wounds can lead to ongoing blood loss within the lung and spilling bronchial blood aspiration into the uninjured lung. It can also lead to hematoma formation, which may convert into an abscess. Whenever, we encounter gun-shot injury in lung parenchyma with an entry and exit wound; ideally, we used to open the tract of bullet and then sew the edges of the lung parenchyma after controlling the bleeding and air leaks. We usually use stapling devices for peripheral lung injuries. If the injury extends to the hilum, often rapid lobectomy or pneumonectomy is required. However, in damage control a large TA stapler can be placed across the vessels and bronchus taking the specimen en bloc. ,,,,
| Intrathoracic Vascular Injury|| |
Small aortic injuries can be sutured directly using the 4/0 non-absorbable suture. Larger injuries, especially to the arch may require temporary digital occlusion and institution of cardiac bypass. The presence of gun-shot wound at neck should arouse the clinical suspicion of great vessel injury. The diagnosis can be confirmed with computed tomography (CT) angiography. The approach to treating penetrating vascular injuries of the thorax begins with planning of exposure to gain proximal and distal control. Median sternotomy or supraclavicular extension or both may be required to provide this exposure.  After exposure and control are obtained, primary repair can be performed. When primary repair cannot be achieved a graft should be placed. For vessels >5 mm, PTFE or knitted Dacron is the conduits of choice. ,, If the patient is in extremis, a temporary shunt or ligation can be placed. In extremis, the subclavian artery can be ligated with the added risk of ischemia. Injuries to the internal jugular or innominate vein can be repaired primarily or ligated. Injuries to the vena cava can also be shunted if repair or reconstruction is not possible. Bleeding from the thoracic outlet can be controlled by transcutaneous placement of a no. 16 or 18 Foley catheter with a 30 cc balloon through the wound tract and traction against the chest wall at the first rib to tamponade the injured vessel. ,
| Tracheobronchial Injury|| |
Injury to the tracheobronchial tree is rare with blunt trauma. , Blunt injuries typically occur as a result of a direct blow to the neck. Penetrating injuries occur most commonly in the cervical trachea followed by the thoracic trachea. Symptoms depend on the location of the injury and whether the injury communicates with the pleural cavity. Cervical injuries usually present with stridor, hemoptysis, subcutaneous emphysema, hoarseness or respiratory distress secondary to an obstructed airway. Thoracic injuries with pleural communication present with pneumothorax. The diagnosis of tracheobronchial injury is made based on clinical findings and radiographic findings (chest radiography and CT scan).
The first step in the management of tracheobronchial injuries is to secure a satisfactory airway patency. However, there is controversy regarding the best method of gaining a secure airway. In emergency situations, where tracheal injury is suspected, securing airway can be done by the placement of the endotracheal (ET) tube surgically through the wound itself. Bronchoscopic-guided intubation is suggested as it allowed safe placement of ET tube. A high index of suspicion is required for rapid diagnosis and prompt surgical repair. During the damage control procedure with a secured airway and a bronchial injury, early clamping of the hilum of the lung can stop an air leak. Injuries to the trachea can be repaired primarily without tension. In the thorax, intercostal muscles, serratus anterior or latissimus dorsi can be used for buttressing of the repair to decrease the risk of leak or fistula formation. In times of extremis, bronchial injuries can be treated with rapid lobectomy or pneumonectomy.
| Esophageal Injury|| |
Blunt esophageal injury is extremely rare. Cervical esophagus is the primary site of involvement due to gunshot wounds or iatrogenic trauma. Clinical presentation depends upon site, size, contamination and presence of other injuries. Symptom includes odynophagia, dysphagia, hematemesis, chest pain and back pain. The diagnosis can be made with the help of endoscopy and CT scan. If <50% of the circumference is injured, primary repair should be the treatment. The repair should be reinforced with intercostal muscle, pleura, pericardium or omentum. If the injury is >50% circumference, exclusion with a cervical esophagostomy and a gastrostomy tube, is one option. A second option is the placement of a salem sump in the esophagus just proximal to the injury along with drainage with a thoracostomy tube. The latter is the preferred choice in the patient with an esophageal injury with poor physiologic reserve. At the definitive operation, the surgeon will decide whether primary repair or diversion should be performed based on timing as well as tissue appearance and the surrounding inflammatory response, though a conservative approach is the best.
| Post-Operative Management in the Intensive Care Unit (ICU)|| |
The post-operative care is as challenging as the initial operation. Effective methods of active warming are forced-air warming or conductive warming, provided that enough skin surface is available. Infusion fluid warming, increasing the operating and post-operative room temperature and warming of irrigation fluids are adjunctive therapies. The choice of rewarming strategy is largely dictated by individual patient characteristics and institutional resources and expertise. Ongoing blood loss in the ICU is a very challenging problem.  It is very difficult to determine whether the bleeding is surgical or non-surgical. Patient who has ongoing surgical bleeding may not correct the coagulopathy or normalize temperature. However, returning an unstable patient to the OR for non-surgical bleeding can prove to be fatal. This decision is made by the surgeon based on judgment. In patients who had temporizing procedures such as shunting of vasculature, ligation of vasculature with planned bypass or those requiring more formal esophageal repair should return to the OR once physiologic criteria have been restored. Hemostasis and closure of the thoracic wall in the standard fashion can be done at this time. At least two large thoracostomy tubes should be placed.
| Protocol of Damage Control in Thoracic Trauma|| |
- Resuscitation: Always follows ABC sequence (airway protection/breathing/ventilation/oxygenation/circulation and bleeding control).
- Indications for surgical intervention: Pneumothorax, hemothorax, cardiac injuries, lung injuries, tracheobronchial tree injuries, traumatic aortic disruption, intrathoracic vascular injuries, traumatic diaphragmatic injuries, esophageal rupture.
- Timing of surgical intervention: Depends upon the patient's physiologic status:
- Immediate (DCT).
- Urgent (in the OR, within 1-6 h of arrival).
- Delayed (24 h after admission).
- Common surgeries included as damage control are: DCT, pneumonorrhaphy, wedge resection, pulmonary tractotomy, lobectomy and pneumonectomy for lung injuries, intracardiac repair for septal defects and valve injuries, coronary artery and myocardial repair, intrathoracic vascular repair, tracheobronchial and esophageal repair.
- Precautions: (A) Avoid underestimating the severity of blunt pulmonary injury. Pulmonary contusion may present with a wide spectrum of clinical signs that are not correlated with chest X-ray findings. (B) Delayed or extensive evaluation of the wide mediastinum without cardiothoracic surgery capabilities may result in an early in-hospital rupture of the contained hematoma and rapid death from exsanguinations. (C) Underestimating the severe pathophysiology of rib fracture is a common pitfall, particularly at the extremes of age.
| Summary|| |
We have described some of most common presentations in thoracic injuries and reporting some general methods of effective management and surgical approaches for exposure and repair of thoracic injuries. The thoracic trauma patient is at primary risk for trauma related complication and death. Though, effective and timely surgical intervention is critical to favorable outcomes.
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