Thoracic injuries

Patients arriving in cardiac arrest may be candidates for rescusitative thoracotomy ( Table 1). This procedure should generally be performed by individuals who are capable of handling intrathoracic injuries. Technical aspects include anterolateral thoracotomy at the nipple line (males) or the inframammary crease (females), opening the pericardium anterior to the phrenic nerve, open-heart massage, rarely atrial cannulation, and packing the thorax to control great vessel bleeding. Cross-clamping the thoracic aorta has been advocated as a routine part of resuscitative thoracotomy to improve cerebral and coronary perfusion, but the exposure may be difficult, and prolonged occlusion may result in both increased ventricular strain and splanchnic ischemia. Aortic occlusion may be better performed by temporary hand compression. Patients who have had emergency thoracotomy and cardiopulmonary resuscitation should be monitored for postpericardiectomy syndrome requiring non-steroidal anti-inflammatory agents. If acute neurological or ECG changes occur, or if there is arrest after intubation, consideration should be given to the occurrence of air embolism, necessitating resuscitative thoracotomy and hilar cross-clamping.

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Table 1 Outcome of resuscitative thoracotomy: predictive factors in patients who arrive in cardiac arrest

After thoracotomy or sternotomy, initial control of cardiac wounds can be achieved with digital pressure, skin staples, or placement of a Foley catheter. Definitive repair is obtained by using sutures buttressed with Teflon or pericardial pledgets. Distal coronary artery injuries can be managed by ligation, but more proximal injuries (usually the left anterior descending artery) may require cardiopulmonary bypass for repair. Traumatic penetrating septal defects can be managed expectantly, but left-sided valvular injuries will almost invariably require formal repair or valve replacement. Postoperative support may include an intra-aortic balloon pump or a partial bypass using heparin-bonded tubing.

Most thoracic injuries require only a chest tube (36-40 French) to allow complete drainage of blood and air. Open wounds can be temporarily covered with a gauze taped along three sides to create a 'flutter valve' prior to tube placement. The critical technical factors include preparation of the chest wall, placing the tube in the mid or anterior axillary line at the nipple line, using a finger to probe the thorax before placing the tube, directing the dissection over the top of a rib and avoiding the neurovascular structures that lie inferior to the ribs, ensuring that the 'last hole' is within the thorax (this can be done rapidly by measuring the tube from the entry site to the suprasternal notch and trimming if needed), and ideally placing the tube to lie posteriorly and apically. In patients who are unstable, time should not be wasted in trying to create a 'tunnel'; rather, one should go directly into the interspace below the skin incision. A thoracotomy is required if there is a massive air leak, an initial hemothorax greater than 2000 ml, or an initial hemothorax greater than 1000 ml followed by outputs of 300 ml/h for 2 to 3 h. Autotransfusion devices using a 40-^m filter should be considered. Patients requiring urgent exploration may be best managed with single-lumen intubation which avoids the risk of extending a bronchial tear (Wa.g.D.eL£La/ 1996). If necessary, the tube can be advanced down the opposite bronchus. In stable patients with unilateral thoracic injuries without evidence suggestive of major tracheobronchial injury, double-lumen intubation and independent-lung ventilation is helpful.

Parenchymal injuries caused by low-velocity bullets do not usually need operative intervention, but pneumorrohaphy and individual ligation of the vessels are favored if persistent bleeding occurs. High-velocity missile and blast injuries, including shotgun injuries, may require complex debridement or lobectomy. Major hilar injuries should be managed by immediate clamping to avoid bleeding and air embolism, with early pneumonectomy if the lung cannot be salvaged. Postoperative interventions after pneumonectomy may include fluid restriction, diuretics, treatment of right ventricular failure with pulmonary vasodilating agents, and possibly selective intubation of the opposite bronchus to avoid barotrauma. Interval rethoracotomy to 'irrigate' the thorax and buttress the bronchial stump with a tissue pedicle may decrease the risk of empyema and bronchopleural fistula.

Patients with severe unilateral lung injury and poor compliance can be managed with placement of the 'good' lung upwards, independent lung ventilation, or selective intubation of the good lung. Severe post-traumatic respiratory distress may require diverse strategies such as the use of high-frequency positive-pressure ventilation, pressure control-inverse ratio ventilation, permissive hypercapnia, or occasionally extracorporeal membrane oxygenation. Rotating the patient (or bed) at intervals of 2 h may also be helpful. Pulmonary hypertension may require vasodilating agents such as dobutamine, isoproterenol (isoprenaline), nitroglycerin, or inhaled nitric oxide, although, in the setting of unilateral injury, pulmonary vascular dilation may increase shunt. Persistent hemothorax can be managed early by thoracoscopic drainage and irrigation, particularly if there is a question of secondary infection, but may require formal thoracotomy. Moderate hemothoraces (less than a third of the thorax) may resolve without significant fibrothorax if left alone. Traumatic psuedocysts are managed expectantly unless they become infected, in which case percutaneous drainage may suffice.

Hemoptysis may occur as a consequence of pulmonary contusion or major vascular injury. In the former situation, the hemoptysis is not usually 'exsanguinating'. If hemoptysis is persistent, the patient should be placed in the reverse Trendelenburg position, have supplemental oxygen administered as well as systemic antibiotics, and undergo bronchoscopy. With severe hemoptysis, the injured side should be placed dependent to prevent the uninjured lung from filling, and in the operating room a bronchial blocker should be placed to isolate the affected side. If lung isolation controls the bleeding, the patient should remain intubated and chemically paralyzed. Serial chest radiographs should be obtained to rule out hidden hemothorax. If there is evidence of continued bleeding after 24 h, or if the initial bleed was significant, pulmonary angiography with embolization should be considered. Persistent bleeding and/or inability to perform embolization is an indication for thoracotomy.

Esophageal injuries, whether cervical or intrathoracic, generally require urgent surgical intervention. Small shotgun pellet injuries without documented leak may be managed non-operatively (Fig 1). If the injury is small, primary repair is sufficient. Larger injuries should be treated with resection, diversion, and/or reconstruction.

Within 24 h, or if contamination is minimal and the patient is stable, primary repair with tissue buttressing (Grillo flap) or resection with primary repair or reconstruction is performed. Injuries initially operated on more than 24 h postinjury often require esophagectomy or exclusion with reconstruction later.

Fig. 1 This patient sustained a shotgun injury to the left chest. During laparotomy, esophagoscopy revealed a pellet 35 cm from the incisors. No leak was demonstrated by insufflation or injection of methylene blue. Postoperative Gastrograffin and thin barium studies also failed to demonstrate a leak. This injury was managed successfully non-operatively.

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