47: Treating Traumatic Chest Injuries in a Limited Resource Setting

Trauma is the leading cause of death in individuals between the ages of 1 and 44. In the Western world, motor vehicle accidents account for the majority of these deaths. In a post 9/11 world, it is difficult to argue that practicing thoracic surgeons should not attain a core level of competency in advanced trauma life support techniques. Traumatic injuries are categorized as blunt, penetrating, or caustic. Surgical techniques for blunt and penetrating esophageal trauma are described in Chapters 48 and 49. Corrosive esophageal injury is discussed in Chapter 50. This chapter concerns the management of blunt and penetrating chest injury in an emergent setting, whether in the field, at a disaster relief facility, a community hospital, or other rural setting, where the thoracic surgeon may be called upon to help manage an acute patient with traumatic thoracic injuries.

Morbidity and mortality from thoracic injuries may be categorized as immediate, within minutes to hours, and late. Pattern recognition and aggressive early treatment are crucial to saving lives, and early proactive interventions can significantly improve immediate and late outcomes. Many of these interventions are considered routine in modern thoracic surgery practice, but require a high level of training and equipment. This chapter reviews the pathophysiology of traumatic thoracic injury and presents some urgent and emergent procedures that can be performed by providers with a basic level of thoracic surgery training and associated competencies working in a limited resource setting.

The principles and procedures described in this chapter follow the Advanced Trauma Life Support (ATLS) Program.¹ Over the past decades, the delivery of trauma care in the United States has greatly benefited by the development of this program, as well as by the development of a system for accrediting regional level I trauma centers. A level 1 facility must meet certain objective parameters of service, expertise, and availability of resources. Unfortunately, the majority of hospitals in the United States remain unaccredited for trauma care or are designated at the lowest level (III). Nevertheless, the need to care for trauma victims at less than a level I setting persists.

Most general thoracic surgical procedures are associated with a higher morbidity and mortality compared with non-thoracic surgical procedures. In the United States, the expected mortality from multiple rib fractures is 3% to 5% in an elderly patient, compared with the estimated mortality for lobectomy of 1% to 5%. Pneumonectomy and esophagectomy have estimated mortalities of 4% to 20% and 2% to 20%, respectively, and all of these values are experience-dependent (i.e., whether the treatment is performed at a high- vs. low-volume center). Hence, successful complex general thoracic procedures should be performed by an experienced team, with expertise in perioperative management, in a well-equipped and well-staffed operating facility. These include, but are not limited to, a surgeon with general thoracic experience; an anesthesia team familiar with one-lung ventilation and epidural anesthesia for pain control; blood bank capabilities; chest imaging; continuous pulse oximetry; oxygen supplementation; intensive as well as intermediate care units; dedicated nursing and physical therapy, as well as respiratory therapy.

The fundamentals of attaining good patient outcomes include accuracy of diagnosis, volume restriction before, during, and after the surgical procedure, excellent pain control, and early ambulation. Volume restriction is critical to preventing right heart failure for which there is no effective treatment. Pain control in the perioperative period is critical to encouraging cough, which aids clearance of secretions to prevent atelectasis and pneumonia, both major causes of postoperative morbidity and mortality.

Therefore, when working in the field or a community hospital with an inexperienced team, poor support systems, and limited resources, major thoracic procedures should only be performed when no other therapeutic option is available. The goal of this chapter is to advise the surgeon with minimal or no thoracic trauma training to recognize “patterns” and identify “simple” procedures that can be used to convert urgent life-threatening situations into salvageable and stable conditions.

The thoracic cavity extends from the thoracic inlet to the diaphragm. The cavity is comprised of 12 ribs anchored to the thoracic vertebra posteriorly and the sternum and costochondral angle anteriorly. This mobile bony cage protects vital structures including the heart, lungs, esophagus, and great vessels. The first seven ribs attach directly to the sternum. The first rib is flat and strong: it requires great force to fracture. The 11th and 12th ribs are floating ribs. Rib fractures in adults can be associated with additional intrathoracic injuries such as lung contusion even when the pleural covering is intact. The ribs of small children are more elastic than adults and thus moderate and sometimes severe injuries occur without fracture. Age, therefore, plays an important role in recognizing patterns that point to associated injuries.

During inspiration the diaphragm contracts moving downward; as the rib cage expands, the sternum is pushed anteriorly and the lung volumes increase. During expiration the diaphragm relaxes as it moves up the rib cage and the lung volumes decrease. A healthy adult breathes approximately 12 times a minute, which amounts to about 17,280 breaths a day. The respiratory rate typically increases with injury. Thus, a disturbance of the respiratory mechanics by trauma, iatrogenic injury, or other reason is a major source of thoracic morbidity and mortality. This is fully addressed in the sections on rib fractures and postoperative pain management below.

The trachea enters the thoracic inlet anterior to the esophagus. In a normal adult, it is approximately 12 cm in length. The carina lies directly behind the angle of Louis. The proximal third can be easily accessed from the neck, the distal third is best accessed from the right chest, while the middle third is difficult to reach and is best accessed with sternotomy. The left mainstem bronchus is 4 cm long and has an acute angle from the carina; it lies between the aortic arch and the pulmonary artery.

During surgery, the anesthesiologist prepares the patient for one-lung ventilation with collapse of the operative lung. This is critical to facilitating a workspace during chest surgery. Additionally, while the lung is collapsed, the blood flows preferentially to the opposite lung, thereby increasing the overall oxygenation of blood during surgery. This physiologic shunting is also important for decreasing the blood loss during surgical procedures on the unventilated lung.

Any injury to the central mediastinal area, often referred to as the “box” (Fig. 47-1), should trigger a low threshold for surgical exploration. It is prudent to remember that young healthy adults have great cardiopulmonary reserve. In the setting of serious trauma, the young adult often may appear to be remarkably “stable,” their body compensating for the injury, only to suddenly collapse and rapidly die.

Ultrasound, chest x-ray, fluoroscopy, and chest computed tomography (CT) may be the only imaging modalities available.

Plain Chest Films

The chest x-ray has been used since 1895 to diagnose diseases of the chest (Fig. 47-2). It is useful for assessing the lungs, heart, chest wall, diaphragm, major vessels, and spinal column as well as soft tissue. The lungs can be assessed for nodules or masses, cavitary lesions, and pleural and pericardial effusions. Additionally, it enables assessment of the great vessels, mediastinal structures, and chest wall. Typically, two types of exams exist:

• The PA and lateral exam consists of two x-rays; the PA or posteroanterior view, where the patient faces the x-ray film, and the lateral view where the patient is turned sideways. Having two views enables more precise recognition and localization of abnormalities. When only a PA view is available, consideration of anatomic landmarks, such as fissures and selective obscuration of anatomic structures, may be adequate for localizing pathology.

• The pleural cavity is examined for pneumo- or hemothorax, with attention to deepening or blunting of the costophrenic angles. The heart and pericardium are assessed for contour; a large contour may be a sign of hemopericardium. Next, the position of the diaphragm is evaluated and the abdominal cavity is examined for free intraperitoneal air and the aeration of the abdominal contents. The bony structures are examined for fracture. The mediastinum is assessed for size as are the great vessel notches and air (Table 47-1).

Ultrasonography

Ultrasound has limited utility in the chest because ultrasonic waves are interrupted by air in the lung. The amplification of ultrasound passing through fluid, however, can provide superior visualization of pleural effusions as well as physiologic information regarding diaphragmatic and cardiac function. In trauma, a study is performed called focused assessment with sonography for trauma (FAST). It is used to assess the abdominal cavity and the pericardium for the presence of blood. The pericardial window is the most sensitive window for blood around the heart. Furthermore, a skilled examiner can also find air or blood in the costophrenic angle as mentioned above.

Fluoroscopy

Fluoroscopy is useful for assessing the esophagus, great vessels, and the diaphragm. Fluoroscopy is a dynamic examination and therefore provides information about the function of the organs examined.

Computed Tomography

CT is the standard examination for chest pathologies today. If available, a chest CT (especially with 3D reconstruction) in a stable patient can accurately diagnose and determine the extent of a traumatic chest injury and is useful for surgical planning.

Management of Thoracic Trauma

When assessing treatment options, triage is critical. The decision to treat or transfer a patient should be based on the provider's level of experience, resources available, and the availability and accessibility to more specialized care. When possible, the immediate emphasis should be on “damage control” as opposed to definitive care. Whenever possible, damage control can and should be expediently performed for life-threatening injuries (e.g., tension pneumothorax) that can be safely and successfully converted to a stable non-life-threatening condition. For other conditions, it may be best to stabilize locally and then transfer the patient to a level I trauma center where he/she can receive a higher level of care.

Thoracic trauma is a significant cause of immediate and delayed patient mortality. There are two major types of thoracic trauma: blunt and penetrating trauma. In contrast to other diseases encountered by a general surgeon, reaction time and pattern recognition are critical for obtaining optimal outcomes.

Basic life-threatening injuries that should be recognized and converted to stable conditions are: (1) loss or obstruction of airway, (2) pneumothorax (tension, hemo, simple), and (3) pericardial tamponade. More advanced situations may include severe intrathoracic hemorrhage (caused by bleeding from the chest wall, cardiac or pulmonary lacerations, or injury to the great vessels). Some injuries like those to the great vessels, especially in the setting of limited resources, might be unsalvageable; whereas a simple laceration of the right ventricle may be easily repaired. Thus, in a minimal resource setting, triage should account for surgical expertise, facilities, equipment, and support needed to salvage the patient. Few patients with thoracic trauma will require a thoracotomy (<10% for blunt injuries, 15%–30% for penetrating injuries). In general, blunt trauma causes more extensive injuries that are harder to repair, while penetrating trauma (especially a stab wound) is easier to repair.

Chest trauma typically leads to lung injury (i.e., contusion, consolidation, and atelectasis) and disruption of chest wall mechanics (i.e., rib fractures, diaphragmatic injuries, muscle contusions, and pain). Over time, this can lead to a vicious cycle of hypoxia, hypercarbia, and acidosis. The majority of patients who suffer from thoracic trauma and reach a medical care facility alive can be managed with small lifesaving interventions. Examples include: (1) surgical airway, (2) tube thoracostomy, and (3) pericardial window. These simple interventions are easy to master and can convert an unstable patient with a life-threatening injury to a stable patient. The late sequelae of chest trauma, particularly rib fracture, lung contusion, and pneumonia, are associated with late preventable deaths in many trauma victims.

The management of thoracic trauma focuses on the principles taught by the ATLS Program for Doctors.¹ The ABC (airway–breathing–circulation) priority is universally important: establishing and maintaining a patent airway, ensuring breathing (i.e., relief of pneumothorax, tension pneumothorax, hemothorax) with external ventilatory support as needed, and aiding circulation (i.e., hemorrhage control, volume resuscitation, relief of tamponade, etc.). Hypoxia is the most serious result of chest injury. It can be due to loss of airway or altered breathing and must be treated immediately. Patients with chest trauma should be examined according to ATLS guidelines:

1. Primary survey

2. Resuscitation and vitals

3. Secondary survey

4. Definitive care

Blunt trauma frequently occurs as a result of motor vehicle accidents and falls. The mechanism of injury and time elapsed will shed light on the severity of the injury as well as the organs likely affected. On examination, the patient's vital signs (pulse, blood pressure, and respiratory rate) and mental status will give an indication of the severity of injury. On physical examination, the trachea should be central in the neck. If the trachea is deviated, pneumothorax should be suspected. The rib cage is examined by pressing along the ribs bilaterally. If a step, instability, or tenderness is found, fractures are suspected. Subcutaneous emphysema, rib fractures, or hemodynamic instability suggest significant injury to the lung (e.g., contusion), possible pneumothorax, and possible significant hemothorax. The lungs as well as heart are auscultated. If the respiratory sounds are distant or nonexistent in one hemithorax or region, a pneumothorax or hemothorax should be suspected. If the patient has distant heart sounds, a narrow pulse pressure, and distended neck veins, a cardiac tamponade should be suspected. It is important to remember that anoxia (and shock) will lead to anxiety, combative behavior, and confusion, which must be managed appropriately by treating the underlying cause and by administering supplemental oxygen, thereby improving oxygenation. Additionally, it is important to remember that patients can exsanguinate into the chest cavity. For all injuries that occur in the field, the question of need for antibiotic coverage should be addressed, as well as tetanus vaccination status and need for vaccination.

Airway

A secure airway must be established swiftly to prevent brain damage from hypoxia (Fig. 47-3).

Foreign-Body Removal

Ingestion of a foreign body is a common life-threatening condition. When a foreign body is lodged within the trachea or bronchial tree proximal to the carina, the patient presents with labored breathing associated with dyspnea and/or fixed wheezing (on inspiration and expiration). This most typically is found in the toddler population as a result of foreign-body aspiration. When the occlusion is complete, it can result in rapid demise leading to respiratory arrest. The initial treatment is to dislodge the object by delivering a succession of forceful blows to the back (i.e., palm slaps between the scapulae) or a Heimlich maneuver (i.e., physician stands behind the patient with fist pressed deeply on epigastrium to induce a rapid increase in intrathoracic pressure which causes the foreign body to dislodge so that it can be coughed up by the patient).

Rigid Bronchoscopy

If these maneuvers fail and the provider is experienced in rigid bronchoscopy, an attempt can be made to remove the object bronchoscopically. Position the patient with his/her head at the edge of the bed, and then anesthetize intravenously with an anesthetic agent such as ketamine. Insert the rigid bronchoscope (a straight hollow tube with light source) perpendicular to the mouth and tongue elevating the epiglottis. Then perform a full extension of the head and cannulation of the trachea. Advance the scope gently into the trachea; the foreign body can be removed piecemeal using a grasper or it can be pushed into the scope and then removed with the scope. If neither is possible, and complete obstruction occurs, the foreign body can be pushed distally into a mainstem bronchus to enable ventilation of one lung, thereby stabilizing the patient.

During rigid bronchoscopy, care must be taken not to break any teeth. Adequate relaxation is crucial. This is a technically demanding procedure that should be performed only by those with proper training or when no other solution exists for reestablishing an airway. In the stable patient, soft tissue x-rays of the neck may aid in viewing a foreign body in the airway.

Caution: When a foreign body causes incomplete occlusion of the trachea and cannot be dislodged by simple noninvasive means and the surgeon is inexperienced in rigid bronchoscopy or does not have the necessary instruments or materials, it may be easier and safer to perform tracheostomy and then apply suction to remove the object through the stoma as described below.

Jet Ventilation

If attempts to remove a foreign body or establish a secure airway are unsuccessful, jet ventilation can be used as a temporary treatment until a secure airway is established. A needle or IV catheter is placed through the cricothyroid membrane and high flow oxygen is administered.

Direct Tracheal Cannulation

Cricothyroidotomy Cricothyroidotomy is performed by opening an urgent surgical airway through the cricothyroid cartilage. This is the quickest, safest, and least technically demanding procedure for relieving a proximal airway obstruction and reestablishing a surgical airway. The cricothyroid cartilage lies anteriorly between the larynx and the first tracheal ring. It is easy to palpate. Pressure in this region causes discomfort. This is the most cranial portion of the trachea. It is also the narrowest portion of the trachea. Cricothyroidotomy should not be performed in children younger than the age of 8 years unless no other option is available, because the first tracheal ring is a complete cartilage ring. Cricothyroidotomy above this level can lead to long-term disability secondary to stricture. Prior to procedure, if possible, the patient should be preoxygenated using a bag mask with jaw maneuver and concentrated oxygen if available.

Equipment needed: #11 blade, endotracheal or tracheotomy tube. Pulse oximetry is suggested. If oximetry is not available, the surgeon must remember that central cyanosis (seen with lip discoloration) correlates with a saturation level <85% in whites but may not be detected until SO₂ drops below 75% in patients with dark skin. Ambo-bag and suction.

Positioning: If the cervical spine has been cleared of injury, a shoulder roll (or 1 L IV fluid bag) is placed horizontally between the scapulae, the patient is positioned supine, and the neck is fully extended. If the cervical spine has not been cleared, the procedure is performed with in-line stabilization.

Procedure: The region of the cricothyroid membrane is avascular. Typically, there is little between the skin and the membrane. A 1 cm vertical midline incision is made in the skin and carried down to the trachea. The cricothyroid membrane is identified and incised horizontally, the stoma is dilated, and the cricothyroidotomy cannula is inserted through the stoma. The cannula is then fixed to the skin using multiple sutures. This procedure has been performed in field situations with improvised means such as using a jack-knife to make the hole and then inserting a car key horizontally and then vertically to stent open the trachea, or using a pen to stab into the cricothyroid ring and then removing the ink carrying cartridge to establish the airway.

Tracheostomy A tracheostomy is a stoma or opening of the trachea that enables direct ventilation, by bypassing the oropharynx, larynx, and proximal trachea. It is the classical approach for acute access to a proximally obstructed airway, or chronic access for long-term ventilatory support, pulmonary toilet, or bypass of a proximal tumor or stricture. A tracheostomy can be performed on individuals of all ages. In the event of prior surgery for a head and neck tumor, where a proximal surgical resection is performed and the proximal trachea is resected, a tracheostoma can be performed in the lower neck or chest. This may require tracheal release maneuvers and is beyond the scope of this chapter. Pitfalls of tracheostomy include loss of airway, injury to posterior membranous wall and or esophagus, tracheo-innominate fistula.

The procedure can be performed at the bedside or in an operating room.

Equipment needed includes: a knife, surgical sutures, needle driver, retractors (two Army–Navy retractors) (Fig. 47-4), a curved snap, a tracheal dilator (or instrument for this purpose), an Ambo-bag, suction, a pulse oximeter (preferred), and tracheostomy cannula. Sterile drapes, antiseptic wash, bovie coagulator, or silver nitrate sticks.

The tracheostomy cannula will usually be cuffed and have a removable cleanable inner cannula. For the average adult, an internal diameter of 8 is adequate; the normal length would be approximately 8 cm. The inner size of the tube should be similar to that of an endotracheal tube. This can be estimated by comparing it to the diameter of the patient's pinky finger. If a tracheostomy tube is not available, an endotracheal tube can be cut above the balloon insufflation tubing and then used as a cannula. The balloon should be tested by inflation and then pressure to assess proper function prior to starting the procedure.

Positioning: see Cricothyroidotomy

Procedure: The neck and upper chest are prepped and draped as is customary. A 1.5-cm incision is made one finger breadth above the sternal notch. This incision can be vertical or horizontal. My preference is horizontal. The skin, the subcutaneous tissue, and the platysma are divided. The long blades of the Army–Navy retractors are now inserted to retract the tissue. The median raphe is divided in the avascular plane. The retractor blades are advanced to retract the strap muscles. The trachea is visualized and elevated by toeing in and pulling up on the retractors. The isthmus of the thyroid is elevated off the trachea to avoid damage to the inferior thyroid vein. Alternatively, the isthmus can be divided, and the vessel ligated. The third tracheal ring is identified. In the event that the patient is being ventilated with a high FiO₂, the FiO₂ is now decreased to less than 40 to prevent airway fire. An anterior portion of the third tracheal ring is resected. Hemostasis is performed using the Bovie or silver nitrate. The tracheostomy is dilated and the tracheostomy tube is inserted. The balloon is inflated, and the patient is ventilated through the newly placed cannula. Meticulous hemostasis is performed; the tube is sutured in place. Ideally, flexible bronchoscopy is performed to confirm correct placement of the cannula (Table 47-2).

Breathing

Breathing must be reestablished expediently to prevent permanent brain damage and respiratory as well as circulatory arrest (Fig. 47-5).

The surgeon must have a high index of suspicion for conditions that prevent breathing in patients with an otherwise patent airway. The most serious of these conditions is tension pneumothorax. When identified, it must be immediately converted from a life-threatening to non-life-threatening condition. Clinical signs of tension pneumothorax include: air hunger, dyspnea, cyanosis, distention of neck veins, tracheal deviation, diminished breath sounds on the side of tracheal deviation, tachycardia or bradycardia, hypotension, severe anxiety, confusion, and combative behavior. Immediate treatment consists of needle decompression.

Once tension pneumothorax is identified, the physician performs a needle decompression. A strong gush of air should immediately exit the chest and the patient should immediately stabilize from a cardiovascular standpoint. If the patient does not completely stabilize, an additional needle can be inserted. If the patient stabilizes, the physician should continue the primary survey according to ATLS protocol, placing a chest tube during the resuscitation phase. Alternatively, if the patient does not stabilize, a chest tube must be immediately placed.

Surgical Therapy for Tension Pneumothorax

Needle Decompression This is the quickest, safest, and least technically demanding procedure for converting a life-threatening tension pneumothorax to a simple pneumothorax. It should be done immediately upon diagnosis.

Equipment needed: A 14- or 16-French IV cannula and an alcohol swab.

Positioning: Supine.

Procedure: The area just under the second rib on the midclavicular line of the affected side is cleaned with an alcohol swab. A 14- or 16-French IV cannula is inserted. An air gush is heard; in the event that the patient does not stabilize, an additional catheter is placed. If this fails to achieve stabilization of the patient, a chest tube is placed.

Caution: Needle decompression of a tension pneumothorax is an emergency measure facilitating temporary stabilization of the patient. This should never be used as the only treatment. Once carried out, a tube thoracostomy set should be opened, prepared, and a chest tube should be placed during the resuscitation phase upon completion of the primary survey.

Tube Thoracostomy The indications and urgency for placing a chest tube must factor into the speed with which the tube is placed (Fig. 47-6). The procedure can be performed anywhere by anyone with proper equipment and training.

A patient suffering from a symptomatic tension pneumothorax which has not been relieved by needle decompression needs an urgent tube placement. The treating doctor must work quickly, focusing only on vital steps (i.e., alcohol swab, incision [larger], relief of tension, placement of tube, and tube anchoring with heavy suture). This is in contrast to a tube placed to drain a chronic effusion or empyema, where proper protocol is followed (see Chapter 9).

A chest tube is a long plastic tube with multiple holes around the circumference of the tip of the tube. Chest tubes come in two shapes: straight or with a right angle. Straight tubes are primarily used to drain air and blood, while right-angle tubes are primarily used to drain pus. Chest tubes are sized according to their diameter, which is recorded in units called French. Straight chest tubes sometimes contain an inner needle or trocar. Typically for adults, a 28-French chest tube will evacuate air, while a 32- to 36-French chest tube would be needed to evacuate blood. Chest tubes are marked with a centimeter scale down the side of the tube. Note: the “zero” does not mark the end of the tube but the last hole. Typically, a straight chest tube should be inserted to the 20 cm mark (from the skin) for an adult female and to the 24 cm for an adult male to assure that it reaches the apex. The tube can always be pulled back, but space contamination can occur if the tube is advanced after initial insertion. The tube is then connected to a drainage system.

After insertion, it is preferable to connect the chest tube to a collecting system on suction. When wall suction is not available alternative suction methods are available (Table 47-3).

Drainage Systems Both open and closed systems may be used for chest tube drainage, but a closed system is preferred because it decreases the likelihood of external infection. With an open system, the chest tube drains openly or into an open bag or canister. Simple systems actively evacuate the effusion by suction, but there is no control over the strength of the suction, and they lack the advantage of water-seal systems. On the other hand, an open system may be the only option available in a minimal resource setting, and it is easy to assemble from reusable glass jars and tubing.

The advantages of more complex closed systems are (1) they separate the patient from the suction by using a water seal (A, B, or C), (2) they have adjustable suction control (B and C), and (3) they have separate drainage and water-seal bottles making it easier to remove the drainage bottle (C) (Fig. 47-7). The addition of a water column enables one to calibrate the suction simply by increasing or decreasing the water column.

We prefer commercially available systems such as Atrium (Fig. 47-8). However, when suction and collection system are not available, draining the tube effluent through a Heimlich valve into a bag is the best option (Fig. 47-9). The Heimlich valve is a one-way flutter valve invented by Henry Heimlich in 1963. It enables air and liquids to evacuate the pleural cavity and then collect in a bag preventing suctioning of external contents into the pleural cavity.

If neither a suction device nor Heimlich valve is available, one has to improvise. The middle finger of a surgical glove can be cut off at the base. Using heavy silk, the “finger” is tied to the end of the chest tube and the distal tip of the finger is removed. The chest tube is then inserted into the middle of a drainage bag and the bag is secured to the chest tube, thus achieving an improvised closed one-way system.

Surgical Therapy Chest Tube Placement

Equipment needed: a knife, Metzenbaum scissors, strong surgical sutures (#1 or 2 silk), needle driver, two Kelly clamps, sterile drapes, and antiseptic wash; 10 to 20 cc of 1% lidocaine. A 10-cc syringe and a 21-gauge long needle.

Anesthesia: Local anesthesia is injected subcutaneously by the surgeon and rib blocks are placed. If available, the patient can receive a small amount of IV conscious sedation.

Antibiotics: Two grams Ancef are given for coverage of skin flora. When treating injury in the field with less sanitary conditions, a broader coverage may be needed.

Positioning: The patient is positioned supine and a folded sheet is placed under the affected side to obtain a 20 to 30 degree elevation. The arm on the affected side is either flexed over the head and taped or strapped straight next to the body in a way that will ensure noninterference during the procedure.

Procedure: A fully gowned, gloved, and masked surgeon preps the chest widely with an alcohol-based solution. The chest is then draped in the area of the fifth intercostal space anterior axillary line. The edge of the nipple is left in view. Three towels are placed to form a triangle. The fifth rib is palpated just posterior to the anterior axillary line, lidocaine is injected under the skin in this area, and then into the deep tissue. Lidocaine (2–3 cc) is now injected just inferior to the lower border of the posterior fourth and fifth ribs. Care is taken to avoid injury to the vein–artery–nerve (VAN) complex. A horizontal incision at least 2½ times the diameter of the chest tube is made through the skin. If the patient is unstable, muscular or obese, or if placement is difficult, the skin incision should be widened (a prudent surgeon would make a larger incision from the start for these patients). Metzenbaum scissors are used to spread the subcutaneous tissue vertically to avoid the thoracodorsal and long thoracic vessels. The apical portion of the fifth rib is palpated and the intercostal muscles anchored into this rib are divided using Metzenbaum scissors. The dissection should be bloodless; all sources of bleeding including inadvertent intercostal injury must be controlled.

It is much easier for a novice to place a chest tube at a 90-degree angle with respect to the skin and ribs. Do not attempt to tunnel the tube. A Kelly clamp is used to split the intercostal muscles along the lower rib. In the event of simple or tension pneumothorax, a rush of air should be heard. In the event of hemothorax, blood and clots will evacuate. In empyema, pus will discharge. If culture or Gram stain is available, the exudate should be removed sterilely in a 10-cc syringe. Empyema as well as effusions can be loculated. Insert a gloved finger into the thoracostomy, feel the lung and chest wall, and rule out significant adhesions. Loculations can be gently broken up using a Yankauer suction. However, care must be taken to avoid causing major bleeding while doing so (by carrying it into the lung or hilar structures). Complete evacuation of the cavity from blood or pus is important for decreasing future morbidity. A straight chest tube is used to evacuate air and blood. It is placed through the minithoracotomy aided by a Kelly clamp or an internal trocar that is pulled back 1 cm. It is inserted with a twisting corkscrew motion pointing toward the posterior chest and then carried apically. If resistance is encountered, the tube should be partially withdrawn and then gently corkscrewed in. For an apical tube, insert the tube to 20 cm for an adult female and 24 cm for adult male. For empyema a right angle tube is placed toward the costophrenic angle. The area around the chest tube is closed in multiple layers. The chest tube is secured with a heavy #2 silk suture, and an omega stay suture is placed around the tube to enable additional anchoring as well as future closure if desired.

Caution: It is NOT advisable to place a chest tube with a trocar fully in place because of the risk of causing injury to additional viscera. However, when the trocar is withdrawn by 1 cm, it makes chest tube insertion simpler since the trocar gives the chest tube firm strength enabling passage through a small thoracotomy, while preventing insertion injuries caused by its sharp point.

Most traumatic injuries of the lung are self-limiting, that is, they will heal on their own with conservative measures. These injuries include lung contusions, intraparenchymal hemorrhage, and air leak due to parenchymal injury. They can usually be managed with simple supportive measures (oxygen supplementation, adequate pain control, early ambulation) or procedures such as tube thoracostomy.

A massive air leak after chest tube insertion may be due to an injury to a major bronchus, typically the proximal mainstem bronchus near its insertion into the carina. These patients present with massive subcutaneous emphysema and tension pneumothorax. Chest tube insertion demonstrates continuous five-column air leak. On chest x-ray, the lung does not reinflate. Additional chest tubes are placed. If despite placement of these tubes the lung does not reinflate, an airway injury is suspected. This is now confirmed with a chest x-ray demonstrating a “dropped lung” despite multiple functioning tubes. The repair is surgical debridement and reimplantation through a posterior lateral approach with interrupted suture.

Rib Fractures Rib fractures may occur in isolation or associated with additional injuries. Multiple rib fractures, even when they represent the sole injury, are associated with an unacceptably high mortality rate of 3% to 5% in elderly patients. This is higher than the expected mortality from an elective lobectomy (range: 1%–5%). Rib fractures are usually accompanied by lung contusion. In addition, they may be associated with hemo-/pneumothorax, parenchymal injury to the liver or spleen, or a major vascular injury. Often rib fractures are diagnosed by a finding of tenderness on physical examination or as a result of findings on chest x-ray. On initial presentation, rib fractures may produce only slight tenderness. Over time (hours to days after injury), however, the broken ribs continue to rub on the exposed periosteum (>17,000 times a day) and the pain cycle gradually increases, leading to decreased lung volumes and splinting of the chest wall. If not treated appropriately, atelectasis can lead to lung consolidation. Ultimately, this may become infected, causing pneumonia.

This cycle should be anticipated and treated prophylactically with an aggressive cocktail of pain medications immediately upon diagnosis. Do not wait for the pain to develop. This cocktail typically includes Tylenol q.6, Motrin q.8, and an opiate for breakthrough pain. If the oral cocktail fails to achieve pain relief, a lidoderm patch can be added and IV non-steroidal anti-inflammatory drugs (NSAIDs) can be given (if kidney function is normal). Alternatively, a thoracic epidural catheter may be placed and epidural patient-controlled anesthesia (EPCA) is initiated or multiple rib blocks are performed. In the setting of multiple rib fractures, an IV PCA drip is suboptimal since it can lead to somnolence and increased respiratory complications. Early ambulation is critical as is the ability to breathe deeply and cough. This will not be possible if the pain is inadequately controlled. These patients should be hospitalized and ambulated aggressively to prevent the known sequelae of multiple rib fractures. This proactive approach has been shown to decrease mortality with multiple fractures.

A subset of patients with rib fractures has instability of the chest. A smaller number experience paradoxical chest wall motion breathing known as “flail chest” (see Chapter 137). This is typically found on physical examination. These patients will need very aggressive pain control to prevent pneumonia. If available, an epidural catheter should be placed and the patient should receive bolus or patient-controlled analgesia for a number of days. Alternatively, multiple rib blocks can be performed, later transitioning to a strong oral cocktail (e.g., Tramadol 75 mg TID, Motrin 600 mg TID, and Tylenol 650 mg QID.). A subset of these patients will require positive pressure ventilation to stabilize the rib cage. Currently, at our medical center, we stabilize the chest wall of patients with flail chest or multiple fractures when the fractures do not involve the most posterior one-third of the rib, since this area is hard to fixate. Typically, this is done through a muscle-preserving posterolateral thoracotomy using metal fixation plates and surgical screws (see Chapter 137). Early results of this technique appear promising in a select subset of patients.

Circulation

Hypovolemic shock is a life-threatening condition in patients with thoracic injuries. To stabilize the patient, one must first identify the mechanism of injury. A number of intrathoracic injuries may lead to hypovolemic shock, including injuries to the great vessels, heart, lungs, and chest wall. Patients with injuries involving the great vessels usually die at the scene. Even in a controlled clinical setting, the repair is complex and beyond the scope of this chapter. A stab wound in “the box” (Fig. 47-1), however, in a hypotensive patient warrants immediate exploration.

The lungs function in a low-pressure system. Therefore, injuries to the lungs generally are more survivable than injuries to the great vessels. Chest wall injuries, including rib fractures, can lead to significant intrathoracic bleeding as well as injury to the lung parenchyma. Undrained blood in the thorax can lead to chronic fibrothorax and may serve as a medium to encourage thoracic space infections. Bleeding within the thoracic space can be caused by rupture of the intercostal vessels, lung laceration, intraparenchymal bleeding, cardiac laceration, and great vessel injury.

Physical examination may show various levels of shock depending on the amount of bleeding the patient has experienced by the time of examination. The patient may be tachycardic or bradycardic, normotensive or hypotensive, or may have cold and clammy extremities and pallor. Anxiety and combative behavior are ominous signs of profound shock. A flail chest, chest wall instability, or tenderness should alert the provider to the presence of possible significant intrathoracic trauma. Decreased and muffled breath sounds may be found with hemothorax. Heart sounds may be distant if the patient has pericardial tamponade secondary to hemopericardium. Volume resuscitation should be limited to the goal of permissive hypotension to optimize the patient's ability to repair his or her injuries.

According to ATLS protocol, two wide-bore IVs are placed peripherally. During the resuscitative phase, a chest x-ray as well as ultrasound is obtained when available. If clinical suspicion exists for hemorrhage into a pleural cavity, with or without imaging, a thoracostomy tube should be expediently placed as previously described. Output on insertion should be recorded as well as hourly output thereafter.

Indications for immediate exploration of the chest include:

• Stable patient with >1500 cc upon initial chest tube insertion or more than one-third the patient's calculated blood volume.

• Persistent blood requirements despite receiving blood products and output greater than 250 cc an hour for a few hours.

• Penetrating trauma to the “box”; medial to the nipple line or scapular tip line.

• Unstable patient with significant hemothorax.

Cardiac Tamponade

Cardiac tamponade is accompanied by Beck's triad, consisting of muffled heart sounds, elevated venous pressure, and decreased arterial pressure. The FAST examination is very sensitive to the detection of pericardial fluid which, in the trauma setting, is assumed to be blood until proved otherwise. In penetrating trauma to the left of the sternum, a left anterior thoracotomy would be the incision of choice. For a right-sided penetrating trauma, a midline sternotomy is recommended.

Cardiac Laceration

Cardiac laceration from anterior penetrating trauma typically involves the right ventricle. It can be approached through an anterolateral thoracotomy or midline sternotomy. The pericardium is opened, and the laceration is repaired with double-armed monofilament pledgeted 2/0 mattress stitches. Care is taken when sewing a beating heart to time the suture with diastole. It is essential to slide the needle smoothly through the tissue to avoid enlarging the hole. If additional stitches are needed, they are placed until complete hemostasis is obtained. Great care must be taken to avoid injury to the coronary vessels.

Emergency Room Thoracotomy: Anterolateral Thoracotomy

Indication: Penetrating trauma, leading to severe shock or witnessed recent loss of signs of life (Fig. 47-10).

Aim: Urgent cross-clamp of aorta, enabling volume resuscitation and rapid control of bleeding source.

Equipment: Alcohol or Betadine, sterile drapes, major thoracotomy tray.

Essential elements include: a large knife, long Metzenbaum scissors, Mayo scissors, DeBakey forceps, mid and long needle drivers, aortic clamps (straight and curved), a large Finochietto retractor, large egg beater retractor. Large laparotomy pads and strong working suction device, cell recycler if possible. Sutures and ties, Teflon pledgets if available (if not pericardium can be used), large chest tubes, and/or Blake tubes (or soft drainage tubes). Underwater (closed) chest tube collecting system (preferably with suction).

Optional but beneficial: linear staplers with reloads (preferably endoGIA staplers), vascular as well as heavy tissue loads.

Technique: The surgeon stands to the patient's left. Using a large blade (22) the surgeon incises the skin rapidly down to the intercostal muscle. In females, the cut is made along the inferior mammary fold, elevating the breast off the inferior aspect of the pectoralis muscle. Next the intercostal muscle is divided along the apical portion of the sixth rib. The chest is entered and a large Finochietto retractor is placed. Using Yankauer suction, blood is removed from the chest, the chest is packed, the injury is systematically assessed, and appropriate action is taken to repair the injury.

The pericardium is incised with Metzenbaum scissors parallel and above the phrenic nerve, taking into account the beating heart to time the surgical actions appropriately. The volume of the resuscitation can be assessed by observing whether the heart is distended or collapsed. If the patient is in extremis and the descending aorta can be dissected circumferentially, this is done by opening the pleura with Metzenbaum scissors. The surgeon then bluntly dissects around the aorta with the index finger taking care not to inadvertently injure the esophagus or directly avulse the intercostal perforators. A straight aortic clamp is placed temporarily enabling rapid resuscitation and providing a short window of opportunity during which the bleeding that led to hypovolemic shock can be controlled.

Modification for Additional Cardiac Exposure

The incision can be extended medially (horizontally) into or beyond the sternum using heavy curved Mayo scissors (Table 47-4).

Surgical Technique Thoracic Procedures

Posterolateral Thoracotomy The two major operations in the chest are the anterolateral thoracotomy, described above, and the posterolateral thoracotomy described here.

Posterolateral thoracotomy provides the best exposure to the lungs, as well as hilum, distal trachea, and bronchial tree and is considered the workhorse of thoracic surgery. On the right, it provides good exposure to the esophagus, azygos vein, and distal trachea.

The patient is placed in full lateral decubitus position which takes time to set up. It requires lung isolation (blocker or double-lumen tube), suboptimal in the acute setting.

The skin incision extends from the anterior axillary line beyond the tip of the scapula. Typically, the latissimus muscle is divided and the serratus muscle is spared. The incision into the intercostal space depends on the planned surgery. The third intercostal space is used for injuries near the thoracic inlet, the fourth intercostal space for injuries of the upper lobes, the fifth for injuries of the lower lobes, and sixth for injuries of the lower esophagus.

Staff Requirements Surgeon and assistant, anesthesiologist, two nurses or operating room technicians (one scrubbed and the other circulating).

Equipment Operating room, adjustable lighting, headlight (the most important light source in thoracic surgery). An adjustable operating room table that enables jackknifing (lateral flexing at hips) of the patient. This fully opens the intercostal spaces for optimal exposure. Beanbag or two round pillows for lateral decubitus positioning. Armrests enabling arm of operated side to be placed in “swimmers position” elevating the scapula and exposing the intercostal spaces. Blankets to wrap lower body and proactively prevent hypothermia. Strong working wall suction device.

Alcohol or Betadine, Sterile Drapes A major thoracotomy tray. Essential elements include: a large knife, long Metzenbaum scissors, Mayo scissors, DeBakey forceps, mid and long needle drivers, multiple long straight and curved clamps, lung compression clamp, aortic clamps (straight and curved), a large Finochietto retractor, large egg beater retractor.

Multiple large laparotomy pads. Large chest tubes and/or Blakes (or soft drainage tubes). Underwater chest tube collecting system (preferably with suction).

Optional but beneficial: Electrocautery, linear staplers with reloads (preferably endoGIA), vascular (30 mm) as well as heavy tissue loads (45–60 mm).

Sutures and Ties (Open as Needed) Availability of monofilament 2/0, 3/0, and 4/0 4 vascular ligation or repair; 2/0 and 3/0 chromic or Vicryl for lung parenchymal resection. Long- and medium-sized clips (if available).

For closure: #1 or 2 Vicryl for rib reapproximation, 0 Vicryl for muscle reapproximation, 2/0 Vicryl for deep subcutaneous tissue closure. For skin closure: skin stapler or absorbable 3/0 suture or 3/0 nylon. A heavy silk suture for securing chest tube to the chest wall.

Anesthesia notes: General or combined.

A mechanical ventilator should be available with ability to give oxygen at increased FiO₂.

The anesthetist requires expertise in positioning a double-lumen endotracheal tube (Note: left-sided tubes are easier to position and work well for most patients or a bronchial blocker, when neither is available). A smaller endotracheal tube can be placed directly in the left mainstem bronchus. This can enable right-sided surgery, with one-lung ventilation. However, it does not allow suctioning of the right lung to hasten collapse. One lung intubation on the right (for left-sided surgery) is problematic, since secure tube placement would necessitate blockage of the right upper lobe and thus lead to suboptimal ventilation during surgery. A fibrotic bronchoscope facilitates accurate placement of tube. Tube placement without fiberoptic guidance can be done with clinical examination and reexamination; however, this is suboptimal to using a bronchoscope. The endotracheal tube is placed by anesthesia with patient in supine position and then affixed appropriately. Thereafter, the patient is turned to lateral decubitus position and tube placement must be reconfirmed.

Remember: The left mainstem bronchus is long and sharply angled. The right mainstem bronchus is short and the right upper lobe typically originates 5 to 15 mm from the carina. Identification of the right upper lobe is made by identifying the three segmental bronchi that have the appearance of a “Mercedes Benz” sign. An epidural catheter can improve the ability to give balanced anesthesia and decreases the need in the postoperative setting for opioids, significantly improving pain management. An epidural should be used for all major general thoracic procedures when possible.

Lines and tubes: Two peripheral wide bore IVs, Foley catheter with urinometer, and nasogastric tube. Optional when needed and if available; arterial line and CVP.

Caution: Any case that would require a Swan-Ganz catheter (marginal patient or extensive procedure) should not be done in the setting of limited resources.

Intraoperative continuous monitoring: O₂ saturation with pulse oximeter, blood pressure with noninvasive cuff on nonoperative arm, cardiac rate and rhythm with EKG.

Fluids

Lactated Ringer's solution or Normosol. Blood products should be available including whole blood or packed red cells and fresh frozen plasma (FFP).

Positioning: On the operating table, place a beanbag covered with a sheet in the area of the patient's chest or two Curlex rolls fully opened, folded in half, and then covered by a bed sheet. The patient is initially positioned supine on the table.

After general anesthesia has been induced, and after placement and confirmation of the double-lumen tube as well as lines and continuous monitoring devices, the patient is turned. This requires four people and is coordinated by anesthesia to assure that the endotracheal tube does not migrate out of position. The patient is moved so the downside is in the middle of the long axis of the operative bed and then the patient is rotated 90 degrees. The patient is lifted and an axillary roll (1 L IV bag) is placed just caudal to the axilla. The beanbag is suctioned or soft rolls are placed in the Curlex. The patient is then slightly elevated and the Curlex tied around the rolls. The lower leg is flexed; a pillow is placed between the legs and the upper leg is left straight. Using heavy tape extending from one side of the bed to the other, the iliac crest is taped and stabilized. The arm on the operative side is placed on an arm board and extended in “swimmers position.” The lower arm is placed on the extended arm board attached the bed or bent upward in a 90-degree angle. Care should be taken to properly pad all possible pressure points and avoid iatrogenic positioning injuries. The bed is now jackknifed to facilitate maximal opening of the intercostal spaces. A grounding pad is placed on the buttocks or thigh. The lower body is covered with blankets or a bear hugger if available.

Prophylaxis: IV antibiotics are given by anesthesia to cover the skin flora (Ancef 2 g or an equivalent) within an hour prior to skin incision. These are redosed by anesthesia as needed, typically every 4 hours. Five thousand units of subcutaneous heparin is given for DVT prophylaxis for all thoracotomies if available. In addition, when available, sequential venous dilators should be placed on the patient's legs.

Technique: The patient is prepped and draped in standard fashion. Wearing headlamps, the surgeon stands at the patient's back.

An electrocautery unit (if available) and two large Yankauer suctions are prepared and the operating lights are adjusted, while anesthesia institutes single-lung ventilation to cease ventilation of the operative lung. It takes approximately 15 to 20 minutes for the nonventilated lung to fully collapse.

A posterolateral incision is made using a large (22) blade to cut a lazy “S” incision along the sixth interspace from the anterior axillary line to beyond the scapular tip. The incision is started one fingerbreadth beneath the tip of the scapula. The skin and the subcutaneous tissues are divided. When dividing the latissimus muscle, it is important to coagulate or tie any vascular bundles encountered. The serratus anterior is mobilized and retracted to spare the muscle. Next, a scapula retractor is placed under the scapula, and the assistant elevates the scapula while the surgeon counts the ribs. The first rib is a flat rib and must be identified to assure that the count as correct. The interspace for entry into the chest is chosen based on the location of injury. The third intercostal space is best for approaching structures near the thoracic inlet (i.e., SVC, subclavian vessels, proximal thoracic trachea, and esophagus). The fourth intercostal space is best for accessing the upper and middle lobes of the lung. The fifth intercostal space is best for accessing injury near the midesophagus and lower lobe. The sixth intercostal space is best for accessing injuries in the region of the diaphragm.

It is important to remember to cut the intercostal muscle fibers along the lower rib of the interspace and not along the upper rib to avoid injury to the VAN bundle which lies beneath the rib. Care should be taken upon initial entrance into the thoracic cavity to avoid lung injury. For most general thoracic cases, incision is made along the fourth or fifth intercostal space. A Finochietto retractor can be placed to open the chest cavity. It should be opened slowly. If additional exposure is needed, the incision can be opened internally by dividing the intercostal muscle insertion along the lower rib medially as well as in the posterior direction. On posterior extension, care must be taken to elevate the erector spinous ligaments from the intercostal muscle so that these are not divided. The retractor is then opened further. If the exposure is still not adequate, a rib can be “shingled” by removing 1 cm of posterior rib. The rib that is shingled is above or below the incision depending on where one needs to gain maximal additional exposure.

Modifications of Standard Incisions for Additional Exposures

Extending the Incision

Standard incisions can be extended in two ways. The incision can be extended internally by medial as well as posterior division of the intercostal muscle along the rib space or the incision can be extended externally by extending the skin incision medially or posteroapically just lateral to the posterior scapula.

Shingling a Rib

If the exposure is not adequate, a rib can be “shingled” by removing 1 cm of posterior rib. The rib that is shingled can be above or below the incision depending on where one needs to gain maximal additional exposure (Table 47-5).

Clam Shell Incision

The clam shell incision (Fig. 47-11) is a curvilinear incision made along the fourth intercostal space (top of fifth rib) and spans between both anterior axillary lines. The mammary vessels are ligated and two Finochietto retractors are used. The incision provides rapid and excellent exposure to the lungs, heart, and great vessels.

Midline Sternotomy

The midline sternotomy (Fig. 47-12) is the workhorse of cardiac surgery. It extends from a point just above the sternal notch down past the xiphoid. This is the classic cardiac surgery incision because it provides excellent exposure to the heart, ascending aorta, aortic arch and its branches, main pulmonary artery trunk, IVC and SVC, innominate artery, and vein. Its only weakness is poor exposure of the left subclavian artery.

Trapdoor Thoracotomy

The so-called trapdoor thoracotomy is a C-shaped incision (Fig. 47-13) that provides optimal exposure to the left subclavian artery. It involves incision along the left clavicle and then curves to the midline along the superior portion of the sternum and then laterally along the fourth rib. A ministernotomy is made from the sternal notch down to the third intercostal space followed by lateral division of the pectoralis and intercostal muscles along the cranial portion of the fourth rib. The incision creates a block consisting of sternum, clavicle, and ribs, which is then retracted laterally, resembling a “trap door.”

Cardiothoracic residents generally do not receive formal training in trauma management, except during general surgery residency. As training programs change, fewer cardiothoracic residents will have had a basic grounding in trauma management. This chapter is a valuable resource for those who rarely manage traumatic thoracic injuries, but who have been called upon urgently to help manage a patient. This chapter is based on the Advanced Trauma Life Support Program for doctors. It is filled with simple practical life-saving tips that are quickly located in an emergent situation.