Albert Chi
Adil H. Haider
Presentation
A 22-year-old male presents to the emergency room with multiple stab wounds to the head, back, and left upper arm. Emergency medical services (EMS) vitals are BP 100/P, HR 104, RR 26, O2, and Sats 97% on room air. Physical examination on arrival reveals that the patient is speaking, but has diminished breath sounds on right, abdomen is soft, has 2+ symmetric pulses distally, and is moving all four extremities. He complains of chest pain and increasing shortness of breath. Initial emergency department (ED) vitals are BP 77/56, HR 126, and Sats 96% on 100% nonrebreather mask.
Differential Diagnosis
When managing unstable patients with penetrating chest injuries, trauma teams must rapidly and accurately intervene with potential life-saving procedures. The airway, breathing, and circulation of trauma run hand in hand in the case of the hypotensive patient with an undetermined underlying cause. Three diagnoses must be considered that need immediate intervention: (1) pericardial tamponade, (2) tension pneumothorax, and (3) ongoing blood loss (e.g., hemorrhage from great vessels, pulmonary hilum, lung parenchyma, or intercostal artery). As interventions and surgical approach are very specific for each of these processes, quick assessment and judgment are necessary.
Workup
In the unstable patient, clinical suspicion and physical exam findings (i.e., breath sounds absent or present, muffled or distant heart sounds) are relied on. Do not delay chest tube thoracostomy tube placement or needle decompression for suspected tension pneumothorax. In the case of suspected cardiac tamponade, a quick Focused Assessment Sonography for Trauma (FAST) pericardial view can determine the presence of fluid surrounding the heart. A clinical caution: even with a negative pericardial window, a cardiac injury can still be present if the pericardial wound communicates with the thorax, decompressing into the chest. In the stable patient, portable upright anterior posterior chest x-ray should be performed with FAST as an adjunct. Computed tomography can be considered for stable patients after primary survey is performed.
Discussion
In this patient, with a penetrating wound to the chest, decreased breath sounds on the side of injury and hypotension, a tension pneumothorax should be assumed. Immediate steps to decompress this must be undertaken.
Chest-Needle Decompression
A simple pneumothorax is the most common thoracic injury after penetrating chest trauma and frequently results from an injury to the lung parenchyma. Without an adequate vent for decompression, increased intrathoracic pressure may result in kinking of the vena cava, decreased venous return to the heart, and cardiovascular collapse. In the prehospital setting, needle decompression is frequently performed on injured patients with a suspected tension pneumothorax. It can be inserted rapidly, with little additional risk to the patient, and is an adequate temporizing measure until a formal tube thoracostomy can be performed.
Key Steps
1. Locate the second intercostal space and the midclavicular line.
2. Prepare site with Chlorhexidine solution or an alcohol swab.
3. Make a puncture with 14-G catheter or angiocatheter from central line kit if additional length is needed secondary to body habitus.
4. Advance until rush of air is encountered and remove needle while stabilizing catheter.
5. Placement of one-way valve if available
6. Confirm resolution of pneumothorax.
Pitfalls
1. Fourteen-gauge catheter length is 1¼ inches, and many patients’ chest walls may require greater length to enter the chest cavity.
2. May cause additional injury to lung parenchyma or even reports of hilar vessel injury from chest-needle decompression
Thoracostomy Tube
Drainage of the pleural space by means of a chest tube is the commonest intervention in thoracic trauma, and it provides definitive treatment in the majority of cases. While a relatively simple procedure, it carries a significant complication rate, reported as between 2% and 10%. While many of these complications are relatively minor, some require operative intervention and deaths still occur (e.g., from laceration of neurovascular bundle in inferior surface of ribs).
A chest tube is indicated to drain the contents of the pleural space. Usually this will be air or blood, but may include other fluids such as chyle or gastric/esophageal contents. Chest tube insertion is also appropriate to prevent the development of a pleural collection, such as after a thoracotomy or to prevent a tension pneumothorax in the ventilated patient with rib fractures.
Absolute Indications
· Pneumothorax (tension, open, or simple)
· Hemothorax
· Traumatic arrest (bilateral)
Relative Indications
· Rib fractures and positive pressure ventilation
· Profound hypoxia/hypotension and penetrating chest injury
· Profound hypoxia/hypotension and unilateral signs to a hemithorax
Key Steps
1. Place the patient’s ipsilateral arm over head to maximize exposure.
2. Don mask, gown and gloves; prep and drape area of insertion, if time allows.
3. Select site for insertion: midaxillary line, between fourth and fifth ribs and the same level of the nipple in males and inframammary line in females.
4. Infiltrate insertion site with local anesthetic, make a 3- to 4-cm incision through skin and subcutaneous tissues between the fourth and fifth ribs, parallel to the rib margins.
5. Use a Kelly clamp to push through the pleura and open the jaws widely, again parallel to the direction of the ribs.
6. Insert finger through your incision and into the thoracic cavity. Make sure you are feeling lung (or empty space) and not liver or spleen.
7. Grasp end of 36 french chest tube with the Kelly forceps (convex angle toward ribs), and insert chest tube through the hole made in the pleura.
8. After tube has entered thoracic cavity, remove Kelly, and manually advance the tube posteriorly and toward the apex of the thoracic cavity.
9. Connect chest tube to pleurovac and place to wall suction.
10. Suture in place with a nonabsorbable suture and place an occlusive dressing.
Pitfalls
· Must confirm with manual palpation of lung parenchyma. An incision placed too low can inadvertently place thoracostomy tubes intra-abdominal and not intrathoracic.
· Blood loss on initial insertion of chest tube. Placement of an additional clamp at the distal end of the chest tube during insertion decreases the amount of spillage and aids in the measurement of estimated blood loss.
· Be careful of potential injury to the chest tube inserter from rib fractures—double gloving is recommended.
Diagnosis and Recommendations
The indications for thoracotomy after traumatic injury typically include persistent shock, arrest at presentation, and ongoing thoracic hemorrhage. Operative intervention due to ongoing hemorrhage is most commonly performed after 1,500 mL of blood output on initial chest tube insertion or continued hourly blood loss of 250 mL or more for 3 consecutive hours after tube thoracostomy. Evidence of gastric contents could also represent an esophageal injury, and massive air leak from chest tube could suggest a bronchial tracheal injury.
Emergent thoracotomy is performed by an anterolateral approach as this provides the most rapid access to the heart and mediastinum. However, if there is time for operative planning, then the incision that provides the best exposure for the suspected injuries should be used.
Anterolateral Thoracotomy
Key Steps to Thoracotomy
1. Place patient in supine position with arms extended.
2. Place double-lumen endotracheal tube by anesthesia if time and stability allow; for injuries to the left chest, the endotracheal tube can be advanced in the right mainstem bronchus keeping the left lung collapsed.
3. Make the incision in the fourth intercostal space starting at the sternal border to the midaxillary line.
4. Anatomic landmarks of the fourth intercostal space is just below the nipple and the inframammary fold in males.
5. Enter the chest with three bold strokes of the knife: the first divides the skin and the subcutaneous tissue, the second through the pectoralis anteriorly and serratus laterally, and the third is through the intercostal muscles entering the pleural space (Figure 1).
FIGURE 1 • The emergent left anterolateral thoracotomy incision should follow the intercostal space.
Pitfalls
· Exposure of certain structure is not always optimal with this standard thoracotomy incision.
· If the Finecetto/rib retractor is placed with the bar/spin mechanism toward the sternum, then it may obstruct extension of the incision across the sternum (clamshell thoracotomy) if required.
Resuscitative Thoracotomy
The best survival results with this procedure are seen in patients who undergo ED thoracotomy for thoracic stab injuries with isolated cardiac stab wounds and arrive with signs of life in the ED. Factors such as mechanism of injury, location of major injury, and signs of life should be taken into account when deciding whether to perform resuscitative thoracotomy in the ED.
Accepted Indications
• Penetrating thoracic injury
Traumatic arrest with previously witnessed cardiac activity (prehospital or in-hospital)
Unresponsive hypotension (BP < 70 mm Hg)
• Blunt thoracic injury
Unresponsive hypotension (BP < 70 mm Hg)
Rapid exsanguination from chest tube (>1,500 mL)
Relative Indications
• Penetrating thoracic injury
Traumatic arrest without previously witnessed cardiac activity
• Penetrating nonthoracic injury
Traumatic arrest with previously witnessed cardiac activity (prehospital or in-hospital)
• Blunt thoracic injuries
Traumatic arrest with previously witnessed cardiac activity (prehospital or in-hospital)
Additional Steps to ED Thoracotomy
1. Create a window and using the Mayo scissors cut along the intercostals avoiding the neurovascular bundle on the inferior portion of the rib cage.
2. Place rib spreader into the incision with the handle toward the axilla and open to expose the workspace.
3. Mobilize the lung by cutting the inferior pulmonary ligament.
4. Manually palpate posterior ribs and palpate the spine; the thoracic aorta should be the first tubular structure encountered.
5. To crossclamp the aorta, open the parietal pleural and place a vascular clamp across. If a nasogastric tube (NGT) is present, the NGT can be used to identify the esophagus.
6. If cardiac tamponade or a cardiac injury is suspected, open the pericardium.
7. To open the pericardium, pinch the left lateral aspect with your finger or clamp anterior to the phrenic nerve and open widely parallel to the nerve sliding scissors along the pericardium.
Pitfalls
· Injury to the aorta, the intercostal arteries, or the esophagus during aortic clamping
· Injury to the phrenic nerve when opening the pericardium
Other Thoracotomy Approaches
The choice of thoracic incision (Figure 2) for trauma repair is based on the anatomic location of injury and physiologic status. There are many incisions available for thoracic trauma. These include anterolateral thoracotomy, transsternal anterolateral “clamshell” thoracotomy, posterolateral thoracotomy, “book incision” (anterolateral thoracotomy, partial upper sternotomy to a supraclavicular extension), and median sternotomy.
FIGURE 2 • Thoracic incisions for trauma include (A) median sternotomy, (B) book thoracotomy, (C) posterolateral thoracotomy, (D) anterolateral thoracotomy, and (E) extension of an anterolateral thoracotomy across the sternum.
The left anterolateral thoracotomy is the utility incision for resuscitation under circumstances of acute deterioration or cardiac arrest. This incision allows exposure for opening the pericardium, open cardiac massage, clamping of the descending thoracic aorta, and treatment of a large percentage of cardiac and left lung injuries.
A left posterolateral thoracotomy allows much greater exposure to the left hilum, including the hilar pulmonary artery, vein, and bronchus. It is also ideal exposure for the descending aorta.
A right posterolateral thoracotomy is indicated for right hilar injuries and also gives excellent exposure of the thoracic portion of the esophagus.
Posterolateral thoracotomy requires the patient to be repositioned in the lateral position and may exacerbate hemodynamic instability in hypovolemic patients. It is particularly well suited for approaching posterior lung parenchymal lacerations and intercostal vessel injuries.
The “book” or “trap door” incision is seldom used but can be considered for exposure of left-sided thoracic outlet injuries. It has the advantage of providing exposure of a long segment of the left common carotid and left subclavian artery. The anterolateral thoracotomy component of this incision can be made above or below the breast, and attention must be paid to the internal mammary artery. The current approach for the management of left subclavian artery injuries is to gain proximal control via anterolateral thoracotomy in the left third interspace combined with a separate clavicular incision for definitive repair.
The standard median sternotomy incision provides excellent exposure to the heart and proximal great vessels, including the ascending aorta innominate artery, and left common carotid artery. It is recommended primarily for anticipated isolated anterior cardiac injuries where there is no need to repair injuries to other organ systems. Further exposure can be obtained with extension into either the supraclavicular area or the neck.
A clamshell thoracotomy provides almost complete exposure to both thoracic cavities. In general, the indication for performing a clamshell thoracotomy is when access is needed to both sides of the chest. For example:
· To improve exposure and access to the heart (especially right-sided structures) following a left anterolateral thoracotomy performed for profound hypotension or traumatic arrest
· To provide access to the right chest in transmediastinal injuries or multiple penetrating injury to both the left and the right chest
· To allow cardiac massage following a right-sided thoracotomy
The only part of the thoracic cavity that is not easily reached through a clamshell incision is the very superior mediastinal vessels. If there is an injury here, the sternum can be split to provide wide exposure to this area.
Intraoperative Management of Specific Injuries
Pulmonary Tractotomy for Penetrating Lung Injury
1. Once the hemithorax is entered, control of the pulmonary hilum can be accomplished with finger occlusion or a clamp. The purpose is prevent passage of air into the systemic circulation as well as hemostatic control.
2. Place a lung clamp on either side of the tract created by the knife or the bullet.
3. Insert a gastrointestinal anastomosis stapler through the entrance and exit wound of the lung.
4. Fire the stapling device to fully expose the injury tract.
5. Directly ligate bleeding vessels or exposed bronchi with 3-0 Vicryl figure eight sutures.
Pitfalls
· Large unsealed areas of the lung may cause persistent blowing air leaks leading to an unplanned reoperation.
Intercostal Bleeding
1. Identify the area of injury.
2. Place a circumferential suture around the rib with an absorbable suture and large needle from within the chest cavity.
3. If necessary, a straight needle may be used to place a suture around the rib and skin and then back into the pleural cavity to get control of the vessels. These sutures can typically be removed after 48 hours.
4. Both ends of the intercostals artery must be ligated.
Pitfalls
• Including the neurovascular bundle may cause rib pain.
Massive Pulmonary Hilar Bleed
1. Attempt to control bleeding with manual pressure, hemostatic suture, or rapid resection of the bleeding segment.
2. If hilar clamping is the only option, hold ventilation to allow manual grasping of the hilum with your nondominant hand.
3. Place Satinsky clamp around the entire hilum.
4. If unable to place clamp, twist the lung to rapidly control the hilum without a clamp.
Pitfalls
· Phrenic nerve injury during clamping
· Hilar clamping is not well tolerated by patient in shock.
Pneumonectomy: Due to the substantial alterations in cardiopulmonary physiology, outcomes after traumatic pneumonectomy are very poor. Thus, this procedure should be reserved only for patients where lung salvage is not possible. That being said the decision to proceed with this highly morbid procedure should be taken quickly and decisively as delaying this usually results in mortality.
Case Conclusion
Based on EMS reports, a chest x-ray plate was present on the ED stretcher upon arrival of the patient, and an x-ray was shot even before the automated blood pressure was measured. As hypotension was noted along with decreased breath sounds on the side of injury, the ED staff immediately performed needle decompression resulting in a rush of air and immediate improvement of blood pressure and ability to breath. The digital x-ray in Figure 3appeared on the screen after needle thoracostomy and demonstrates the large tension pneumothorax prior to decompression. Note how the mediastinal structures have been shifted into the left chest. A right chest tube was then placed, which drained approximately 2 L of frank blood on insertion. This prompted emergent transfer of the patient to the operating room for a right-sided posterolateral thoracotomy. Upon exploration, a posterior intercostal artery laceration due to the stab wound was found, but no pulmonary injury was noted. The intercostal artery was ligated with large sutures placed around the rib. Two chest tubes were placed intraoperatively and managed expectantly. The importance of rapid operative intervention can be gauged from the fact that the patient’s initial pH on arterial blood gas was 7.09. Intraoperatively, the patient was resuscitated with 1:1:1 ratio of packed red blood cells, fresh frozen plasma, and platelets. By the end of the case and with reversal of hemorrhagic shock, the patient’s arterial pH had normalized to 7.32. The patient was discharged home on postoperative day 4 without complications.
FIGURE 3 • Chest X-ray prior to needle thoracostomy, which demonstrates a large tension pneumothorax.
TAKE HOME POINTS
· In patients with altered hemodynamics after penetrating chest injury, immediate action directed at reversing the most likely cause of instability must be taken.
· Negative FAST exam does not rule out a pericardial violation or a cardiac injury.
· Most patients with penetrating injury (up to 75%) are simply managed with a tube thoracostomy.
· If 1,500 mL of blood drains out of chest tube immediately, then the patient most likely needs an operative intervention.
· In the operating room, choice of incision is dictated by suspicion of injured structures.
SUGGESTED READINGS
Mattox KL, Wall MJ Jr, LeMaire SA. Injury to the thoracic great vessels. In: More EE, Feliciano DV, Mattox KL, eds. Trauma. 5th ed. New York: McGraw-Hill, 2004:571–581.
Rhee PM, Acosta J, Bridgeman A, et al. Survival after emergency department thoracotomy: review of published data from the past 25 years. J Am Coll Surg. 2000;190:288–298.
Wall MJ, Hirshberg A, Mattox KL. Pulmonary tractotomy with selective vascular ligation for penetrating injuries to the lung. Am J Surg. 1994;168:665–669.
Wall MJ Jr, Soltero E, Mattox KL. Penetrating trauma. In: Pearson FG, Cooper JD, Deslauruers J, et al., eds. Thoracic Surgery. 2nd ed. New York, NY: Churchill Livingstone, 2002:1858–1863.