1. A patient with thoracic trauma for whom acute surgical intervention is planned has a life-threatening injury by definition. Therefore, the patient should be positioned to maximize options for necessary interventions: supine with arms out, prepped from chin to knees and chest to elbows. Large-bore access (IV, IO, or central venous) should be in place, and the airway secured with a cuffed endotracheal tube.
2. For a patient with penetrating thoracic trauma who is in extremis or who is profoundly unstable, left anterolateral thoracotomy is the incision of choice and should be combined with right tube thoracostomy. This incision can be extended across the midline (as a “clamshell” incision) for suspected intra-pericardial injury or right pleural space bleeding.
3. For a patient with palpable pulses and penetrating chest wound with hemopericardium, sternotomy is usually the preferred initial incision. If the diagnosis of hemopericardium is uncertain (ultrasound is unavailable or equivocal but there is a high clinical suspicion for cardiac injury), sternotomy should be preceded by subxiphoid pericardial window.
4. The management of subclavian vascular injuries is challenging. For suspected proximal left subclavian arterial injury, left anterior thoracotomy in the third interspace is a safe initial incision for proximal control. Proximal control of the right subclavian artery is best achieved via median sternotomy. Intravascular balloon occlusion is an additional option to obtain proximal control of injuries to the great vessels. Refer to the JTS Vascular Injury CPG for further details.12
5. For repair of a subclavian artery injury after proximal control, the left or right proximal to mid-subclavian artery can be exposed via a supraclavicular incision. An infraclavicular incision provides exposure to the more distal subclavian artery and the subclavian vein. For more complex subclavian vascular injuries, a trapdoor incision will provide maximal exposure.
6. Lung parenchymal injuries should be resected in a non-anatomic fashion if possible. Anatomic resections should be performed only if the entire lobe has been damaged and is not salvageable. Trauma pneumonectomy should only be performed with non-salvageable hilar injuries and is associated with an extremely high mortality.
7. Posterolateral thoracotomy is rarely appropriate in the acute trauma setting. It is not appropriate in the damage control setting since it does not allow extension into frequently injured adjacent body cavities (abdomen, neck). It may be indicated for definitive repair of posterior mediastinal or lung injuries in a well-resuscitated patient after other injuries have been excluded or addressed.
8. In a patient with combined penetrating chest and abdominal trauma with hemodynamic instability, rapid insertion of bilateral chest tubes and midline laparotomy with pericardial window through the anterior diaphragm will allow for assessment of bleeding from all major body cavities. When needed, laparotomy can be extended to a sternotomy (for a positive pericardial window) or a separate anterolateral thoracotomy incision can be performed for ongoing pleural space hemorrhage. When the diaphragm is lacerated, an abdominal source of bleeding may present as bleeding into the chest cavity.
9. As described below, damage control philosophy and strategies apply to emergency thoracic surgery as well. Gauze packing and hemostatic adjuncts can help achieve temporary hemostasis of chest wall defects or injuries at the apex of the hemithorax.13 Uncontrolled bleeding from the lung, pulmonary hilum or thoracic aorta can be packed as well.14 Due to risk of iatrogenic tamponade, avoid packing of the pericardium.
10. Temporary chest closure can be considered after damage control procedures, or when there is concern for thoracic compartment syndrome due to massive resuscitation. Closure can be performed using a negative pressure vacuum closure or simply a large adhesive drape with a large-bore chest tube for drainage and suction.14