Appendix B: Specific Thoracic Injury Management 19,20

Open Pneumothorax

1. Treat by placing a chest tube through a separate incision and sealing the hole with an occlusive dressing. Complex chest wall defects may eventually require closure with mesh or muscle flap coverage at higher roles of care.
2. For patients with difficulty breathing, hypoxia or with large sucking chest wounds, maintain a low threshold to intubate prior to transport as positive pressure ventilation will overcome the effect of the sucking chest wound.

Flail Chest

1. Generally associated with significant underlying lung contusion, which must be managed aggressively with supplemental oxygen and a low threshold for intubation and mechanical ventilation prior to air transport (or protracted ground evacuation).
2. In an awake patient with flail chest, pain control is critical to optimize pulmonary mechanics, although the use of intravenous narcotics must be balanced with the risk of respiratory depression.
3. Tube thoracostomy is appropriate prior to medical evacuation for any patient with flail chest, regardless of whether a pneumothorax or hemothorax is clinically evident.
4. There is a role for surgical stabilization of rib fractures (SSRF) in patients with flail chest or select patients with severely displaced rib fractures. SSRF should not be performed in a contaminated field, requires specialized equipment, and should only be done by surgeons familiar with the technique. For casualties undergoing further evacuation, SSRF should usually await Role 4 care. When performed, the original chest tube should be removed, the site cleaned and if possible excluded from the operative field and a new chest tube placed to reduce the risk of post-operative wound infection and osteomyelitis.

Thoracic Vascular Injuries

1. The initial management of a thoracic vascular injury should be manual occlusion with a finger (for an artery) or a sponge stick (for a large vein). Temporary control can allow for additional resuscitation and exposure prior to attempted repair. For an aortic injury, a side-biting clamp may be placed (after aortic mobilization) for temporary control.
2. Repair of vessels should follow the principles detailed in the JTS CPG on Vascular Injuries, with shunting or repair by autogenous or synthetic grafts as indicated.
3. Incising the inferior pulmonary ligament mobilizes the lung to provide better exposure.

Cardiac Injuries

1. Isolated cardiac injuries are exposed by opening the pericardium and placing pericardial stay sutures.
2. Temporary control may be achieved with digital pressure, the use of a Foley catheter, or with skin staples.
3. For definitive repair, use pledgeted horizontal mattress sutures (2-0 or 3-0 polypropylene) on a large, tapered needle (MH or SH). Autologous pericardium can be used if commercial pledgets are not available. Sutures must be tied only to the point of hemostasis to avoid tearing potentially friable cardiac muscle. Take care to place sutures to avoid ligating coronary vessels.
4. Atrial injuries may be controlled with a side-biting clamp, followed by running closure with 2-0 or 3-0 polypropylene suture.
5. Temporary inflow occlusion (occluding the superior and inferior venae for brief intervals) may prove helpful in repair.
6. If distal coronary artery injuries are identified, they should be ligated to control the bleeding.

Parenchymal Lung Injuries

1. Posterolateral thoracotomy is preferred for isolated lung injuries, but is only appropriate in a stable patient with adequate resuscitation and no other uncontrolled injuries. Anterolateral thoracotomy is more appropriate in the urgent or damage control setting.
2. Simple pulmonary parenchymal tears/bleeding may be repaired with absorbable suture on a tapered needle, or may be repaired with stapling of the lung parenchyma (with a GIA or TA middle-thickness staple load).
3. For deeper through-and-through injuries, a tractotomy may be performed by opening the injury tract with a GIA stapler or between straight vascular clamps, followed by running suture repair to control bleeding and air leaks from the exposed lung parenchyma.
4. For more severe/destructive lung injuries, non-anatomic partial lung resection with serial GIA stapler fires may be needed.
5. Hilar injuries or large parenchymal injuries with uncontrolled bleeding or massive air leak may require manual control of the hilum followed by hilar clamping for temporary control. Good communication with the anesthesia provider is essential to manage the resultant sudden decrease in lung volume and right heart strain. If repair is still not possible, pneumonectomy should be considered as a last resort due to the low survival associated with pneumonectomy in a trauma setting.

Tracheobronchial Injuries

1. Airway control is the most important priority, and should be combined with tube thoracostomy(s). If after endotracheal intubation in a patient with a suspected airway injury, ventilation appears adequate and there is no other surgical indication, further intervention should be deferred to a higher role of care.
2. If there is difficulty with ventilation of the patient after tube thoracostomy due to a large air leak, the chest tube should be placed to water seal instead of suction.
3. When intervention is needed, median sternotomy (with cervical extension) provides exposure for the proximal and mid-trachea. Alternatively, cervical tracheal injuries can be approached from a collar incision. The distal trachea, carina, and proximal mainstem bronchi can only be visualized well via right posterolateral thoracotomy (with appropriate lung isolation). Injuries to the distal left mainstem bronchus or more distal left-sided bronchial tree generally require left thoracotomy for repair.
4. Tracheobronchial repair should employ absorbable suture (e.g., polydioxanone or polyglactin), buttressed with pleural tissue or with intercostal or strap muscle wherever possible.

Esophageal Injuries

1. Most often will be identified during the course of exploration for other penetrating mediastinal injuries.
2. Although the resources for definitive repair may not be available in a deployed setting, the key principles in treatment are 1) adequate fluid resuscitation, 2) broad spectrum antibiotics, 3) debridement of any clearly non-viable tissue, 4) control of ongoing contamination, and 5) wide drainage.
3. For patients undergoing damage control procedures, chest tube drainage and a nasogastric tube placed above the level of injury are temporizing measures.
4. The preferred approach for intrathoracic esophageal injuries in a stable patient is posterolateral thoracotomy: right for the upper and mid-esophagus and left for the lower esophagus. Incising the inferior pulmonary ligament mobilizes the lung to provide better exposure.
5. Locate the injury by mobilizing the esophagus (aided by placement of a nasogastric or orogastric tube). Where possible, primary repair is preferred. After mobilizing the esophageal muscle above and below the mucosal injury to ensure complete visualization of the defect, the injury is repaired with a single layer or two layers of 3-0 absorbable sutures.
6. Buttress with muscle (intercostal or strap muscles, pericardium, diaphragm, etc.) should be used. Do not wrap the repair circumferentially. Drains should be placed near the repair.
7. If primary repair is not possible, wide drainage with proximal esophageal diversion should be considered. Resection should only be utilized in the setting of extensive tissue devitalization.

Diaphragm Injuries

1. Most often encountered at the time of abdominal exploration, all injuries of the diaphragm should be closed. If identified at the time of thoracotomy, one must evaluate for associated intra-abdominal injury. In the damage control setting, repair of diaphragm lacerations can be deferred until re-exploration.
2. The majority of injuries can be repaired with nonabsorbable running or interrupted sutures, 2-0 or larger. Mesh repair may be necessary but should be used with caution in the face of contamination.
3. Central tendon injuries of the pericardial diaphragm are rare, but when they occur they can cause tamponade physiology due to either cardiac herniation into the abdomen or herniation of the small or large intestine into the pericardium. Prior to closing central tendon tears, copiously irrigate the pericardial space with warm saline to wash out blood clots or enteric contents and carefully inspect the heart and pleural pericardium to ensure there are no other injuries or tears.23

Chest Wall Bleeding

1. Unlike bleeding from the low-pressure vascular system of the lung parenchyma, bleeding from intercostal arteries reflects systemic pressure and often will not resolve with tube thoracostomy alone.
2. Chest wall bleeding will typically be encountered after an anterolateral thoracotomy for massive or persistent chest tube bleeding. After assessing for non-chest wall bleeding sources, chest wall bleeding can almost always be temporized with manual pressure and packing. Temporary cessation of ventilation may allow for more accurate assessment and control of a chest wall bleeding site.
3. One must be cognizant of the subclavian vessels, which are closely associated with the anteroapical chest wall. If significant chest wall bleeding appears to be arising from this location, additional supra- or infraclavicular incisional exposure may be needed.
4. Once a direct site of chest wall bleeding is identified, it can be controlled with clips, suture, or cautery. Placing figure-of-eight pericostal sutures using a large, blunt needle (CT or MH) around the involved rib (proximal and distal to the bleeding site) may be effective.
5. Adequate visualization may require enlarging an incision, or making a separate counter-incision to improve the angle of approach.
6. In an unstable patient, chest wall bleeding can be temporized with packing using gauze or hemostatic adjuncts.

Concomitant Injuries

1. As described above, the management of patients with suspected combined thoracic and abdominal penetrating injury depends on initial stability.
2. In the face of hemodynamic collapse or loss of vital signs, emergency resuscitative thoracotomy is indicated for temporary control of thoracic bleeding, assessment for intra-pericardial bleeding, control of the descending thoracic aorta, and open cardiac massage.
3. In unstable patients with combined thoracic and abdominal injuries, or when CT scan is not available, midline laparotomy with tube thoracostomy (unilateral or bilateral, depending on injury pattern) and trans-diaphragmatic pericardial window is a safe approach.
4. For patients with combined injuries of the neck and chest, a cervical incision can easily be extended into a median sternotomy (for cardiac or great vessel injury or for proximal control of the right subclavian or either carotid artery), or into right or left supra- or infraclavicular incisions (for subclavian vascular injuries). In addition, a separate anterior or anterolateral thoracotomy may be indicated based on tube thoracostomy output or the need for proximal control of the left subclavian artery.

Trans-Mediastinal Wounds

1. Penetrating wounds which traverse the mediastinum via one or both pleural spaces represent a highly complex injury pattern, and every intra-thoracic structure is at risk. Intra-cardiac injuries (valve or septal injury) should also be suspected with this pattern of injury.
2. At the Role 2 level, care for suspected trans-mediastinal injury (after ensuring adequate airway and intravenous/intra-osseous access) should consist of bilateral tube thoracostomy and assessment for intrapericardial bleeding. Following the algorithms outlined above, surgical intervention may be appropriate. For unstable patients with suspected trans-mediastinal penetrating injury, a left anterior thoracotomy with right chest tube should be performed, with conversion to clamshell incision when needed to address intrapericardial or right chest bleeding.
3. At the Role 3 level with a hemodynamically stable patient, CT imaging should be performed to better estimate the missile trajectory(s), allowing a determination of structures at high risk for injury (keeping in mind that high-velocity weapons can inflict significant destruction outside the direct missile path). Using intravenous contrast with the CT allows assessment for vascular injuries without the need for invasive diagnostic angiography. Where available, esophagoscopy and bronchoscopy may be indicated if there is clinical or radiographic evidence of esophageal or tracheobronchial injury, respectively. Echocardiography can be utilized to assess for cardiac valvular injuries or septal defects. Definitive repair of these injuries can usually be delayed and should await Role 4 where the appropriate expertise and support is available.

Retained Hemothorax

1. Retained hemothorax is defined as undrained blood after 72 hours of tube thoracostomy drainage. Except under extenuating circumstances (such as protracted delay for medical evacuation), the treatment of retained hemothorax should be deferred to Role 3 or higher where CT imaging is available.
2. If a retained hemothorax is suspected by a chest X-ray, CT imaging should be obtained. If the volume of undrained blood is estimated at greater than 300cc and if it is felt to be clinically significant, then additional drainage intervention should be considered.24
3. Additional drainage procedures may consist of an additional tube thoracostomy (low yield after 24 hours), video assisted thoracoscopic surgery (VATS) drainage, image-guided drainage catheters or instillation of intrapleural thrombolytics. None of these approaches has demonstrated clear superiority.25 Thoracotomy may be required if less invasive interventions fail.
4. The intra-pleural administration of thrombolytics is an established but unproven adjunct to chest tube drainage for retained traumatic hemothorax. In the absence of active bleeding or other typical contraindications to thrombolytic therapy and in the absence of an ongoing air leak (which would contraindicate a period of clamping the chest tube), 50mg of alteplase (tPA) in 100ml of normal saline may be administered into the pleural space via chest tube utilizing sterile technique. The chest tube should be clamped for several hours, then placed back on suction. This treatment can be repeated daily for up to three days. tPA will generally be available in a 1mg/ml concentration, such that the 50mg/50ml dose of tPA should be combined 1:1 with 50ml of sterile saline.