Damage control surgery for thoracic injuries
Introduction
The main principles of damage control were developed with regard to controlling ongoing bleeding and contamination of the abdominal cavity in the presence of hypothermia, coagulopathy and metabolic acidosis during the initial operation.21., 22. Subsequently, the patient would undergo resuscitation in the intensive care unit and return to the operating room under more desirable physiologic criteria for completion of their operation. These principles apply as well for patients sustaining thoracic trauma displaying signs of physiologic exhaustion. As opposed to abdominal damage control, there are intra-thoracic injuries that require definitive repair at the initial operation, as well as those that can be temporised. Therefore, the approach to thoracic damage control should be to perform procedures that are technically faster and simpler for definitive repair and to perform manoeuvres to temporise those injuries that do not require immediate repair in the patient in extremis.15., 32. This approach, the abbreviated thoracotomy, has been described in the literature and decreased predicted mortality of 59% to actual mortality of 36%.26 A guide to the different aspects of damage control of the thoracic cavity ensues.
Section snippets
Emergency department thoracotomy (EDT)
All damage control for victims of trauma begins in the emergency department. The patient most likely to require damage control for intra-thoracic injury is the unstable patient with penetrating chest trauma. Patients requiring emergency department thoracotomy for blunt thoracic trauma have a dismal survival rate and are therefore not advocated unless specific criteria are met.2., 8., 30. A definitive airway should be secured whether by endotracheal tube or by surgical techniques. Thoracostomy
Operating room (OR)
In the operating room the patient is placed in supine position with both upper extremities extended laterally and slightly cephalad. For patients who have had emergency department thoracotomy, a longitudinal roll is placed just to the left of the spine over the length of the thorax posteriorly to rotate the patient slightly in the left AO position to about 15°. The patient is prepped and draped from the neck to the knees so that the groin is available in the event that the saphenous vein is
Cardiac injury
Cardiac injuries temporised during the initial EDT can be reinforced if necessary using a 3.0 or 4.0 propylene pledgeted suture. Pledgets can be fashioned from Teflon or pericardium.12 They allow for compression of the cardiac musculature by the suture while preventing the suture from tearing through the myocardium. Suturing widely below the vessel repairs lacerations in close proximity to coronary vessels. This will tent the vessel upward upon tying the suture. Distal coronary artery
Lung injury
Less than 20% of patients undergoing thoracotomy for trauma will require a lung resection.9., 20., 24., 25. The treatments of lung injuries include pneumonorraphy, wedge resection, pulmonary tractotomy, lobectomy and pneumonectomy. Pneumonorraphy, or oversewing of the entrance and exit wounds, can lead to ongoing bleeding within the lung parenchyma and spilling bronchial blood aspiration into the uninjured lung. Adequate haemostasis must be present before using this technique. Peripheral
Intrathoracic vascular injury
The approach to treating penetrating vascular injuries of the thorax begins with planning of exposure to gain optimal proximal and distal control. The patient with a damage control procedure likely already has an anterolateral thoracotomy, which may allow for good proximal control, but frequently does not provide for adequate distal control or exposure for repair. Median sternotomy or supraclavicular extension or both may be required to provide this exposure, however the “trap door” incision
Tracheobronchial injury
The distal half of the trachea is located intrathoracically. Injury to the tracheobronchial tree is rare. Blunt trauma is the most frequent cause of trauma to this region of the trachea, however as discussed earlier, emergent thoracotomy for blunt trauma is almost always futile due to other associated injuries. Approximately 18% of distal tracheal or bronchial injuries are due to penetrating trauma.1., 17. As with any trauma patient an airway should be secured prior to other interventions. In
Oesophageal injury
The majority of oesophageal injuries are a result of gun shot wounds. Blunt oesophageal injury is exceedingly rare. The treatment should be primary repair if less than 50% of the circumference is injured. The repair should be reinforced with pleura, intercostal muscle, pericardium, or omentum. If the injury is greater than 50% circumference, exclusion with a cervical esophagostomy and a gastrostomy tube, which can be placed once physiologic order has been restored is one option. A second is
Intraoperative coagulopathy
The management of ongoing bleeding or “oozing” in the cold, coagulopathic patient with intra-abdominal trauma is frequently managed by packing off the abdomen and providing some form of biological dressing to the abdomen. Once this is achieved the patient is taken for arteriogram to embolize bleeding vessels or to the intensive care unit for warming, correcting coagulopathy and resuscitating the patient. This is rarely an option in thoracic injuries. Cardiopulmonary physiology with the
Temporary thoracic closure
Closure of a damage control thoracotomy can present perplexing problems. Frequently once intrathoracic bleeding has been alleviated the major source of blood loss comes from the vascular thoracic wall. The cold, coagulopathic patient may have surgical or non-surgical bleeding coming from this source. In times of extremis, towel clips can be placed across the incision to temporarily close the thoracic cavity so as to decrease heat loss. However, towel clips do not provide for hemostasis of the
Postoperative care in the intensive care unit
The postoperative care can be as challenging as the initial operation if not more. The main points of part two of damage control can be applied here with rewarming, correcting coagulopathy and resuscitation.6., 22. If arteriography is necessary for bleeding, this should be accomplished prior to transfer to the intensive care unit. Patients with lung injuries that have been managed by pneumonorraphy, wedge resection, or tractotomy should have aggressive pulmonary toilet with therapeutic
Complications
Two common complications that are unique to this patient population are cardiac tamponade and air leak. Cardiac tamponade presents as hypotension, jugular venous distension and muffled heart sounds. If a pulmonary artery catheter is present, equalisation of pulmonary and systemic pressures may be seen. Echocardiography can be of value in making the diagnosis. Treatment consists of opening the wound to release the tamponade. Air leaks should be attempted to be managed conservatively with
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