Damage control surgery for thoracic injuries

doi:10.1016/j.injury.2004.03.002

Injury

Volume 35, Issue 7, July 2004, Pages 649-654

https://doi.org/10.1016/j.injury.2004.03.002 Get rights and content

Abstract

Damage control of thoracic injuries begins frequently with an emergency department thoracotomy via an anterolateral incision. Bleeding and air leaks are quickly temporised. As opposed to abdominal damage control where most injuries can be temporised, most thoracic injuries require initial definitive repair. Thus, 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. There are some injuries that can be temporised and require re-operation once physiologic normality has been achieved.

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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Cited by (71)

Emergency thoracic surgery patients have worse risk-adjusted outcomes than non-emergency patients
2023, Surgery (United States)
Outcomes for patients undergoing emergency thoracic operations have not been well described. This study was designed to compare postoperative outcomes among patients undergoing emergency versus nonemergency thoracic operations.
We retrospectively analyzed the American College of Surgeons National Surgical Quality Improvement Program database (2005–2018). We identified patients who underwent emergency thoracic operations using current procedural technology codes. Patients were then sorted into 1 of 4 cohorts: lung and chest wall, hiatal hernia, esophagus, and pericardium. Emergency versus nonemergency outcomes were compared. Univariate logistic regression was performed with “emergency status” as the independent variable and 30-day postoperative outcomes as the dependent variables. Multiple logistic regression models were performed to control for preoperative factors.
Of 90,398 thoracic operations analyzed, 4,044 (4.5%) were emergency. Common emergency operations were pericardial window (n = 580, 10.2%), laparoscopic hiatal hernia repair (n = 366, 8.9%), thoracoscopic partial lung decortication (n = 334, 8.1%), thoracoscopic wedge resection (n = 301, 7.3%), thoracoscopic total lung decortication (n = 256, 6.2%), and open repair of hiatal hernia without mesh (n = 254, 6.2%). In all 4 cohorts, 30-day postoperative complications occurred more frequently after emergency surgery. After controlling for patient characteristics, 8 complications were more frequent after emergency lung and chest wall surgery, 5 complications were more frequent after emergency hiatal hernia surgery, and 3 complications were more frequent after emergency pericardium surgery. Risk-adjusted complications were not different after emergency esophageal surgery.
Patients undergoing emergency thoracic operations have worse risk-adjusted outcomes than those undergoing nonemergency thoracic operations. Subset analysis is needed to determine what factors contribute to increased adverse outcomes in specific patient populations.
Damage Control Thoracotomy: A Systematic Review of Techniques and Outcomes
2021, Injury
: Damage control surgery is the practice of delaying definitive management of traumatic injuries by controlling hemorrhage in the operating room and restoring normal physiology in the intensive care unit prior to definitive therapy. Presently, damage control or “abbreviated” laparotomy is used extensively for abdominal trauma in an unstable patient. The application of a damage control approach in thoracic trauma is less established and there is a paucity of literature supporting or refuting this practice. We aimed to systematically review the current data on damage control thoracotomy (DCT), to identify gaps in the literature and techniques in temporary closure.
: An electronic literature search of Pubmed, MEDLINE, and the Cochrane Database of Collected Reviews from 1972-2018 was performed using the keywords “thoracic,” “damage control,” and “thoracotomy.” Studies were included if they reported the use of DCT following thoracic trauma and included survival as an outcome.
: Of 723 studies, seven met inclusion criteria for a total of a 130 DCT operations. Gauze packing with temporary closure of the skin with suture was the most frequently reported form of closure. The overall survival rate for the seven studies was 67%. Survival rates ranged from 42-77%. Average injury severity score was 30, and 64% of injuries were penetrating in nature. The most common complications included infections (57%; pneumonia, empyema, wound infection, bacteremia), respiratory failure (21%), ARDS (8%), and renal failure (18%).
: DCT may be associated with improved survival in the critically injured patient population. Delaying definitive operation by temporarily closing the thorax in order to allow time to restore normal physiology may be considered as a strategy in the unstable thoracic trauma patient population. The impact an open chest has on respiratory physiology remains inconclusive as well as best mechanisms of temporary closure. Multi-center studies are required to elucidate these important questions.
An expandable one-way-valve device for chest wound treatment: Evaluation of open pneumothorax in a canine model
2020, Asian Journal of Surgery
Thoracic injuries commonly occur after blunt or penetrating trauma, leading to a blowing wound. For thoracic damage control in emergency, we evaluated a novel chest wound treatment device manufactured using expandable material with a one-way valve, and compared it with closed thoracic drainage for first-line treatment of traumatic pneumothorax in a canine model.
Twenty beagle dogs (10 males and 10 females) were randomly and equally divided into two groups. After arteriovenous catheterization, an open pneumothorax model was established in the beagle dog using a minimally invasive procedure. The experimental group was treated using our test device, while the control group was treated by closed thoracic drainage. Animal survival, oxygen saturation (SO₂), oxygen pressure (PO₂), and changes in chest radiograph with reference to open pneumothorax before and after intervention were recorded at 30, 60, and 120 min.
After a 24-h experimental period, all animals survived. The control group recovered more quickly than the experimental group at 30 min post-trauma. However, the indices were close to normal 120 min after the test device was inserted. During the puncture, chest-wall hemorrhage was stopped by using the device, whereas the control group experienced continual errhysis. The lung had almost re-expanded at the end of the experiment in both groups. The effect of pulmonary re-expansion in the control group was better than that in the experimental group at 120 min.
The novel expandable one-way valve device is a safe and useful tool for the treatment of open chest trauma in emergency based on our animal experiment.
Specific elements of thoracic wound management
2017, Journal of Visceral Surgery
Treatment of air leak in polytrauma patients with blunt chest injury
2017, Injury
Citation Excerpt :
Another possible problem is the presence of a prolonged air leak, defined as a persisting air leak for >5 days, which is thought to be associated with more severe lung lacerations and has shown to often result in significantly prolonged hospital stays [7]. The best treatment of this condition, regarding the optimal timing and type of surgical intervention, remains debated in the literature [1,4,6]. The objective of this study was to evaluate the incidence, characteristics, and treatment of air leak in a population of polytrauma patients with blunt chest injury.
Precise diagnostics and an adequate therapeutic approach are mandatory in the treatment of air leak in polytrauma patients with blunt chest trauma. The aim of this study was to evaluate the incidence, characteristics, and management of air leak following this injury pattern.
Data from 110 polytrauma patients was collected retrospectively. Fifty-four patients received initial treatment by chest tube placement for pneumothorax. These patients were classified into two groups, one with severe air leak and one with minor air leak. An evaluation of injury pattern, chest wall injuries in particular, duration of air leak, reason for drainage maintenance in place, hospital length of stay, ICU stay, ventilator duration, type of treatment, and the delay to surgical intervention was performed.
Whereas 4 patients showed severe air leak and were subsequently scheduled for timely surgical intervention, the remaining 50 patients only showed minor air leak. Only 7 patients with minor air leak suffered from prolonged air leak (>5 days), which spontaneously resolved in all of them after a mean duration of 7.7 days (range 6–12 days). Absence of a prolonged air leak resulted in a shorter length of stay and a shorter duration of mechanical ventilation, although no statistical significance was observed.
Early spontaneous cessation of most minor air leaks as well as early surgical intervention for severe air leak lead to very satisfactory patient outcomes with a relatively short hospital stay in our patients. We therefore advocate early surgery for lacerations of the pulmonary parenchyma resulting in severe air leak, whereas minor air leaks can usually be treated conservatively.
Damage control surgery
2017, Praticien en Anesthesie Reanimation
Lors de la prise en charge des polytraumatisés, le concept de damage control (DCS) chirurgical consiste à substituer à la chirurgie conventionnelle longue, délabrante, hémorragique et hypothermisante des interventions peu délabrantes et non hémorragiques, d’une durée inférieure à 1 heure, accessibles aux chirurgiens généraux. Les objectifs sont le contrôle rapide des hémorragies, la restauration d’une hématose efficace (aérostase), le contrôle du sepsis (coprostase, urostase, parage), l’immobilisation des segments de membres. Les trois critères majeurs qui indiquent cette option thérapeutique sont : pH < 7,2 ; pression artérielle systolique < 90 mmHg, température centrale < 34 °C. Les indications peropératoires sont liées au type de lésions rencontrées, au type et à la durée de la chirurgie nécessaire au traitement des lésions et aux variables physiologiques du patient. La chirurgie de « second look » est réalisée dès que l’état général du patient le permet, après correction des troubles de la coagulation, de l’hypothermie, de l’acidose et du choc hémodynamique.
Damage control surgery is indicated in patients suffering from multiple trauma to avoid aggressive and haemorrhagic, long-duration surgical procedures, performed by general surgeons. Procedures of less than one hour, aim controlling haemorrhage, restoring tissues’ perfusion, controlling sepsis, and immobilizing fractured limbs. The decision is based on three main criteria: pH < 7.2; systolic arterial pressure < 90 mmHg, body temperature < 34 °C. Surgical procedures depend on trauma and organs damage. A second look is performed when the patient status has improved, including a normal coagulation process, the correction of hypothermia, blood acidosis and shock.

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Damage control surgery for thoracic injuries

Abstract

Introduction

Section snippets

Emergency department thoracotomy (EDT)

Operating room (OR)

Cardiac injury

Lung injury

Intrathoracic vascular injury

Tracheobronchial injury

Oesophageal injury

Intraoperative coagulopathy

Temporary thoracic closure

Postoperative care in the intensive care unit

Complications

Surg. Clin. North Am.

Surg Clin North Am.

Injury

Am. J. Surg.

J. Thorac. Cardiovasc Surg.

Surg. Clin. North Am.

Injury

Ann. Thorac. Surg.

Surg. Clin. North Am.

Surg. Clin. North Am.

Surg. Clin. North Am.

Am. J. Surg.

Am. J. Surg.

Injuries of the trachea and bronchi

Thorax

Emergency pneumonectomy for penetrating and blunt trauma

Am. Surg.

Lung-sparing techniques are associated with improved outcome compared with anatomic resection for severe lung injuries

J. Trauma

Transcutaneous balloon catheter tamponade for definitive control of subclavian venous injuries: case reports

J. Trauma