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TREATMENT
Approach Considerations
Any organ within the chest is potentially susceptible to penetrating trauma, and each should be
considered when evaluating a patient with thoracic injury. [17] These organs include the chest
wall; the lung and pleura; the tracheobronchial system, including the esophagus, diaphragm,
thoracic blood vessels, and thoracic duct; and the heart and mediastinal structures.
There has been an incremental increase in the utilization of cardiothoracic surgeons over the
last 10 years for thoracic trauma operative intervention; with little data available, this does
appear to have resulted in improved patient outcomes. [18]
Surgical Therapy
Chest wall injury
The chest serves the important functions of respiration and of protection of the vital
intrathoracic and upper abdominal organs from externally applied force and is composed of the
rigid structure of the rib cage, clavicles, sternum, scapulae, and heavy overlying musculature.
Most wounds to these structures can be managed nonoperatively or by simple techniques such
as tube thoracostomy. The treatment of a stable patient with a normal initial chest radiograph
remains controversial.
Ammons and coworkers further defined the role of outpatient observation of selected patients
with nonpenetrating thoracic GSWs and stab wounds. In their study, observation for 6 hours
with subsequent repeat chest radiography revealed a 7% rate of delayed pneumothorax, and
hospitalization was avoided in 86% of patients treated according to this protocol.
Large, open, chest wall defect closure can be a formidable task. When techniques involving
closure with autogenous tissue of myocutaneous flaps based on the trapezius, rectus
abdominis, pectoral, or latissimus dorsi muscles fail, prosthetic material (eg, polypropylene
mesh, expanded polytetrafluoroethylene, cyanoacrylate) may be used.
Rarely, chest wall hemorrhage from the muscular, intercostal, and internal mammary arteries
can result in exsanguination and may require operative control.
First and second rib fractures are often accompanied by serious associated injuries, particularly
if multiple rib fractures are evident. Treatment of any associated injuries must be expeditious.
Severe thoracic injury that causes paradoxical motion of segments of the chest wall has been
termed flail chest, which may be categorized by size or location. In adults, pulmonary
contusion accompanies flail chest injuries in approximately half the patients.
The primary treatment of chest wall injuries is a combination of pain control, aggressive
pulmonary and physical therapy, selective use of intubation and ventilation, and close
observation for respiratory decompensation. Sufficient evidence now supports the notion that
the pathophysiologic findings associated with severe chest wall trauma are related to the
underlying injuries, chiefly pulmonary contusion and parenchymal injuries, and have little to do
with the movement of the chest wall.
Indications for operative fixation of the chest wall or sternum include the following:
Lung injuries
Injuries related to the pleural space can generally be divided into pneumothorax or
hemothorax. Most patients with such injuries can be cared for with a simple tube thoracostomy.
A massive hemothorax is defined as more than 1500 mL of blood in the pleural space. Usually,
200-300 mL of blood must collect in the pleural space before a hemothorax can be detected on
a chest radiograph.
Pulmonary parenchymal lacerations result in bleeding and air leaks, and the vast majority of
these lacerations can be treated with tube thoracostomy. These lacerations extend from the
surface of the lung toward the hilum or the trajectory of the penetrating object. They can vary
from minor lacerations to lobar bisection. Of penetrating injuries that require thoracostomy,
80-90% can be managed using simple measures (eg, stapling, tractotomy, oversewing).
Fewer than 3% of all patients who require thoracotomy require a pneumonectomy, and this
procedure is reserved for patients with severe hilar vascular injuries. Postoperatively,
aggressive diuresis and selective lung ventilation may reduce the prevalence of pulmonary
edema and stump dehiscence.
Tracheobronchial injuries
Up to 75-80% of penetrating injuries involve the cervical trachea, while 75-80% of blunt injuries
occur within 2.5 cm of the carina. These injuries always occur with other injuries, especially to
the great vessels; without early recognition and prompt intervention, they frequently are fatal.
Esophageal injuries
The exact prevalence of injury to the esophagus due to external trauma is unknown but is less
than 1% of patients with injuries admitted to hospitals. The majority of esophageal injuries are
due to penetrating trauma from a variety of instruments (ie, iatrogenic trauma).
Recognizing injury to the esophagus following trauma is difficult because of the rarity of injuries
to this organ, the paucity of clinical signs in the initial 24 hours, and/or the presence of multiple
other injuries. Delayed treatment results in the rapid development of sepsis and an associated
high risk of death; therefore, any possibility of injury must prompt aggressive investigation,
including radiography, endoscopy, and thoracoscopy (when warranted). The combined use of
these techniques has a sensitivity of almost 100%.
Operative management is dictated by the site of primary injury, associated injuries, condition of
the patient, degree of local suppuration, condition of the esophageal tissues, and delay since
injury.
Primary repair with adequate tissue buttressing and drainage is the preferred method.
Exclusion-diversion procedures have been advocated when primary repair is thought to be
contraindicated. Esophageal replacement, when required, is, at best, a poor substitute for the
original organ.
Complications after esophageal repair include esophageal leaks and fistulae, wound infections,
mediastinitis, empyema, sepsis, and pneumonia. Long-term complications, such as esophageal
stricture, are also possible.
Diaphragmatic injury
Importantly, no distinctive signs and symptoms are associated with penetrating diaphragmatic
injuries. A high index of suspicion is usually required for diagnosis.
Up to 13% of injuries are missed in emergent settings, and the patient may present years later
when visceral herniation occurs (85% within 3 y), manifesting as decreased cardiopulmonary
reserve, obstruction, or frank sepsis. Bowel strangulation and gangrene are associated with a
high mortality rate.
The great vessels of the chest include the aorta, its major branches at the arch (eg,
innominate, carotid, subclavian), and the major pulmonary arteries. The primary venous
conduits include the superior and inferior vena cavae and their main tributaries, as well as the
pulmonary veins. Damage to vascular structures depends on the specific location and degree
of vessel disruption; arterial injuries are more rapidly fatal. The prevalence of great vessel
injuries ranges from 0.3-10%.
More than 90% of thoracic great vessel injuries are caused by penetrating trauma (ie, gunshot,
shrapnel, stab wounds, therapeutic misadventures). Historically, thoracic injuries are
associated with a high morbidity rate; however, Pate and coworkers reported a 71% survival
rate in patients who reach the hospital alive after penetrating chest injuries. The trauma
surgeon must resuscitate, diagnose, and treat the patient within minutes following admission to
the trauma emergency unit.
A patient's hemodynamic stability dictates the next phase of managing a penetrating great
vessel injury. Patients who are stable after initial resuscitation are best served by a further
diagnostic workup. Helical CT, CT angiography, and transesophageal echocardiography offer
several advantages over other diagnostic studies.
Patients who remain in extremis or show continued rapid hemodynamic deterioration are best
served by an emergency thoracotomy for rapid descending aortic cross-clamping and manual
control of bleeding. Patients who are successfully resuscitated but remain hemodynamically
unstable or who demonstrate continued massive blood loss are unable to undergo a further
diagnostic workup and are immediately taken to the operating room.
A choice of proper incision in order to gain adequate exposure for control and repair of the
injury is of prime importance. The median sternotomy with supraclavicular extensions for
access to the subclavian vessels is the most useful incision. The posterolateral thoracotomy is
the incision of choice for access to the descending thoracic aorta. The trapdoor, or book,
incision has historic significance only.
Operative repair of thoracic aortic injuries is virtually always possible by lateral aortorrhaphy
with extremely short cross-clamp times. Rarely, if ever, is an interposition graft required.
Adjunctive measures of cardiopulmonary bypass, temporary bypass shunts, or active aortic
shunts (eg, a centrifugal pump) are usually not described for use in patients with penetrating
trauma but are almost exclusively used for blunt injury. Paraplegia has only rarely been
reported following successful repair of penetrating thoracic aortic injury, even after prolonged
aortic cross-clamping following emergency thoracotomy.
Because of the proximity of other organs to the thoracic great vessels, an additional diagnostic
workup including bronchoscopy, esophagoscopy, and echocardiography may be necessary.
The timing of these interventions continues to be debated. Patients with great vessel injuries
have a higher prevalence of associated venous, esophageal, and bronchial plexus injuries
compared with patients without great vessel injuries. Trauma patients with severe concomitant
injuries who are unlikely to tolerate operative repair may be treated more frequently with
endovascular stenting in the future. Mitchell's series of stent graft repair of thoracic aortic
lesions includes 7 posttraumatic cases.
The Society for Vascular Surgery published data regarding the use of endovascular grafts in
the treatment of acute aortic transections; 97% were due to a motor vehicle accident. Sixty
symptomatic patients were treated with an aortic endograft, with a mean operative time of 125
minutes and an all-cause mortality rate of 9.1% at 30 days. [20]
Nonoperative treatment predominantly applies to patients with blunt aortic injuries who are
unlikely to benefit from immediate repair (eg, minor intimal defects, small pseudoaneurysms).
The long-term natural history of these minor vascular injuries remains uncertain; therefore,
careful follow-up monitoring, including serial imaging studies, is a critical component of
nonoperative treatment.
Cardiac injuries
Traumatic cardiac penetration is highly lethal, with case fatality rates of 70-80%. The degree of
anatomic injury and occurrence of cardiac standstill, both related to the mechanism of injury,
determine survival probability. Patients who reach the hospital before cardiac arrest occurs
usually survive. Those patients surviving penetrating injury to the heart without coronary or
valvular injury can be expected to regain normal cardiac function on long-term follow up. [21]
Ventricular injuries are more common than atrial injuries, and the right side is involved more
often than the left side. In 1997, Brown and Grover noted the following distribution of
penetrating cardiac injuries: [22]
The Beck triad (ie, high venous pressure, low arterial pressure, muffled heart sounds) is
documented in only 10-30% of patients who have proven tamponade. [23]
Pericardiocentesis can be both diagnostic and therapeutic, although some centers report a
false-negative rate of 80% and a false-positive rate of 33%. This procedure is reserved for
patients with significant hemodynamic compromise without another likely etiology.
Echocardiography is a rapid, noninvasive, and accurate test for pericardial fluid. It has a
sensitivity of at least 95% and is now incorporated into the Focused Assessment with
Sonography for Trauma (FAST) protocol. Once again, the management algorithm is based on
the patient's hemodynamic status, with patients who are in extremis or who are profoundly
unstable benefiting from emergency thoracotomy with ongoing aggressive resuscitation. In
patients with GSWs from high-caliber missiles, the absence of an organized cardiac rhythm
portends a grave prognosis. For patients with stab wounds or GSWs from low-caliber missiles
who are apparently lifeless upon arrival, resuscitative thoracotomy is justified.
Stable patients with cardiac wounds may be diagnosed using a subxiphoid pericardial window.
Bleeding must be rapidly controlled using finger occlusion, sutures, or staples. Inflow occlusion
and cardiopulmonary bypass are rarely necessary. Distal coronary injuries are usually ligated,
whereas proximal injuries may require bypass grafts. Intracardiac shunts or valvular injuries in
patients who survive are usually minor and do not require emergent repair. Foreign bodies in
the left cardiac chambers must be removed.
Follow-up
For patient education resources, see the Procedures Center and Skin, Hair, and Nails Center,
as well as Bronchoscopy and Puncture Wound.
Complications
Retained pulmonary parenchymal foreign bodies
The decision to remove a retained foreign body depends on its size, its location, and any
specific problems associated with it. Objects larger than 1.5 cm in diameter, centrally located
missiles, irregularly shaped objects, and missiles associated with evidence of contamination
may be prophylactically removed. Typically, such removal is best performed 2-3 weeks
following the acute injury.
A chest wall hernia is usually a complication of thoracotomy. A patient with a chest wall hernia
presents with pain and an obvious defect, but occasionally a lung may be entrapped and
become necrotic. Management includes resection of nonviable tissue and closure with tissue
flaps or artificial material
Pulmonary hematoma
Hematomas form in 4-11% of patients with pulmonary contusions and are observed more
frequently in patients with blunt trauma. Symptoms of fever and hemoptysis usually abate in 1
week, although chest radiograph findings usually demonstrate resolution within 4 weeks.
Hematomas are associated with an increased prevalence of abscess formation.
Systemic air embolism is usually described following central penetrating lung injury and is a
special risk following primary blast injuries to the lungs. Air can enter the left side of the heart
through bronchial and pulmonary venous fistulae and embolize to the coronary and systemic
circulations. A precipitating factor is often the institution of positive-pressure ventilation with
resulting air being forced into the low-pressure pulmonary venules. Embolism can also occur
with any thoracic great vessel injury. Manifestations include seizures, arrhythmias, and cardiac
arrest. Resuscitation requires thoracotomy, clamping of the pulmonary hilum, and aspiration of
air from the left ventricle and ascending aorta. Experience with hyperbaric oxygen therapy has
generally been good but is usually reserved for those centers with access to larger chambers
(ie, to support associated medical personnel).
Bronchial stricture
Missed tracheobronchial laceration may result in significant strictures. Patients present with
variable degrees of dyspnea. Evaluation with bronchoscopy and CT scanning is followed by
treatment with open operative repair or stenting.
Tracheoesophageal fistula
Traumatic air leaks that last longer than 7 days are unlikely to resolve spontaneously, and
judicious manipulation of the chest tube to increase or decrease the suction may be
appropriate in order to facilitate healing. Bronchopleural fistulae imply a direct communication
between the major airways and the pleural space and usually require some form of intervention
for closure.
Empyema
Empyema occurs in 2-6% of patients with PCT. Traumatic empyema differs from nontraumatic
forms because it is more often loculated and requires operative debridement. Initial treatment is
tube drainage. Thoracoscopy, particularly if performed within 7-10 days, is effective for draining
the infection.
Ventilator-associated pneumonia
Missile embolization
Embolization to the pulmonary arteries is usually treated with surgical removal or interventional
techniques. A chest radiograph taken immediately preceding incision or intraoperative
fluoroscopy is mandatory in order to detect more distal embolization that may occur during
positioning. Asymptomatic patients with small distal fragments may be treated expectantly.
Occasionally, missile emboli may migrate through a patent foramen ovale or from central
parenchymal or vascular injuries to gain access to the left side of the heart and then to the
systemic circulation.
Cardiovascular fistulae
Most cardiovascular arterial-to-venous fistulae occur following stab wounds. Virtually all
manifest as a machinery murmur after approximately 1 week. Innominate artery-to-vein fistulae
are the most common. Patients with coronary artery fistulae, usually to the right ventricle,
present with ischemia, cardiomyopathy, pulmonary hypertension, or bacterial endocarditis.
Aortocardiac, aortopulmonary, and aortoesophageal fistula are quite rare because the
probability of survival from the acute injury is slim. While requiring open repair in the past,
interventional techniques may be used in a large number of these patients.
Injuries to the thoracic great vessels may be complicated by concomitant thoracic duct injury,
which, if unrecognized, may produce devastating morbidity due to severe nutritional depletion.
Initial management of a delayed chylothorax is always aggressive but nonoperative.
Hyperalimentation with total enteral foodstuff restriction (ie, parenteral hyperalimentation) may
result in a significant number of spontaneously sealing thoracic duct injuries. Failure to
spontaneously seal after 5-7 days indicates the need for surgical intervention, which should be
individualized because the optimal approach is controversial. The number of proponents for
direct suture control is equal to the number of those preferring a right thoracotomy to ligate the
vessel as it traverses the diaphragm. Experienced personnel can approach the duct
thoracoscopically or with video assistance, thus minimizing additional discomfort to the patient.
Guidelines for initiation of emergency department thoracotomy were published in 2003, [25] and
the Eastern Association for the Study of Trauma published its own guideline in 2015. [11]
Reporting from a single center in 2010, patients who died had a significantly lower systolic
blood pressure (42 36 mm Hg) compared with those who survived (83 27 mm Hg). [26]
unstable patients.
The mechanism of thoracic injury in modern battles is shifting more from penetrating wounds to
combination blast injuries. The mortality of those injured has increased (12% vs 3% in Vietnam)
and may represent the devastation caused by IEDs and the subsequent multisystem injuries
they cause. The overall killed-in-action rate has decreased, whereas the died-of-wounds rate
has increased. Half of all thoracic injuries reported from the battle front on the Global War on
Terror occurred in the civilian population. [6]