Medicine Notes Penetrating Chest Injuries

1. Hemothorax and Pneumothorax – most common chest injury from blunt and penetrating thoracic trauma
Thoracotomy Indications
- Significant Initial/Ongoing Hemorrhage from Tube Thoracostomy
- Certain Imaging-Identified Diagnosis
Nonoperative treatment may be given even if tube output is more than 1.0-1.5L, GIVEN that the (1) OUTPUT CEASES, and
(2) LUNGS are RE-EXPANDED
Noted Injuries
1. Great Vessels
2. Heart
3. Trachea, Bronchi, and Lung Parenchyma
4. Esophagus
5. Chest Wall and Diaphragm
GREAT VESSELS
- 90% of injuries are due to PENETRATING TRAUMA
- Blunt trauma may cause injury to the INNOMINATE ARTERY
(i.e. brachiocephalic trunk), SUBCLAVIAL ARTERY,
DESCENDING AORTA
o May cause pseudoaneurysm
o May cause frank rupture

2. Ascending and Transverse Aortic Arch – lateral aortorrhaphy
Posterior Injuries or requiring interposition Grafting of the Arch – Full Cardiopulmonary Bypass
Repair of Complex Injuries – Circulatory Arrest
Innominate Artery – Bypass Exclusion Technique
Subclavian Artery – lateral arteriorrhaphy or PTFE graft interposition (i.e. anastomosis is not advocated due to multiple
branches and tethering)
Descending thoracic aortic injuries – urgent intervention (i.e. descending thoracic < intracranial, intra-abdominal, unstable
pelvic fractures); uses partial left heart bypass
PTFE (i.e. POLY-TETRA-FLUORO-ETHYLENE) graft
Pharmacologic Intervention
- Prevent aortic rupture
- Esmolol (i.e. Selective B1 Agonist)
o Target SBP < 100 mmHg
o Target HR < 100 bpm
Mainstay Treatment for Aortic Injuries – endovascular stenting
Endovascular Techniques Appropriation
- patients who cannot tolerate single lung ventilation
- patients > 60 y/o
- patients with risk for cardiac decompensation in aortic clamping
- patients with uncontrolled intracranial hypertension
Descending Aorta Open Repair
- right lateral decubitus position
- hips and legs rotated at 45 degrees to access left groin for femoral artery cannulation
- left posterolateral thoracotomy at 4th
rib to expose aortic arch and left lung hilum
- left heart bypass by cannulating superior pulmonary vein with return through the left common femoral artery
- Centrifugal Pump
o Flow 2.5-4.0 L per minute
o maintains distal perfusion of > 65 mmHg
o function
▪ prevents ischemic injury to the spinal cord
▪ prevents ischemic injury to the splanchnic bed
▪ reduces left ventricular afterload
- Heparinization is not required, esp. in patients with intracranial hemorrhage
- Low-Dose Heparin (100 U/kg) to target ACT (i.e. activated clotting time) of 250
seconds to prevent thromboembolic events
The activated clotting time (ACT) is a test that is used primarily to monitor high doses
of unfractionated (standard) heparin therapy.
- Removal of air and potential clot in pulmonary vein is important during decannulation to prevent emboli to
systemic circulation.

3. HEART
- Blunt and penetrating cardiac injuries have different presentations
- Mostly stab wounds can be repaired operatively
Sequence for Penetrating Injuries
- Control hemorrhage
- Atria damage can be clamped with Satinsky Vascular Clamps
- Majority of ventricular woulds can be occulded with digital pressure
- Left ventricular lesions with skin staples
- Right ventricle with pledgets to prevent sutures from pulling through thinner myocardium
- Injuries adjacent to coronary arteries with horizontal mattress sutures (i.e. since running sutures result in
occlusion and distal infarction)
- Gunshot (i.e. may be stellate or contusions) wounds result in friable adjacent myocardium – repair is not
hemostatic, so use of surgical adhesives (BioGlue) is used
- Echocardiography can be used to diagnose injury and evaluate heart function
- Valve and septal involvement do not necessarily need immediate repair and cardiopulmonary bypass, need to
follow-up ECHO
Sequence for Blunt Injuries
- Typically presents with:
o persistent tachycardia
o conduction disturbances
o tamponade due to atrial or right ventricular rupture
- no pathognomonic ECG findings and biomarkers
- suspicion of contusion AND stable
o monitored for dysrhythmias for 24h by telemetry
- suspicion of contusion AND unstable
o ECHO for evaluation
▪ Wall motion
▪ Pericardial fluid
▪ Valvular dysfunction
▪ Chordae rupture
▪ Ejection Fraction
o Vasoactive agents may be required
Pledgets – prevent sutures from pulling through the thinner myocardium
Trachea, Bronchi, and Lung Parenchyma
- Less than 1%
- Blunt injuries most commonly occur within 2.5 cm of carina
- Initial control of injury for ventilation
Principle of Repair
- Debridement
- Anastomosis
- Limited Dissection (i.e. within the area of injury to avoid bronchial vasculature and subsequent ischemia and
strictures)

4. Expectant management for injuries < 1/3 of airway circumference WITH NO evidence of persistent air leak (i.e. after using
biomicroscopically directed fibril glue in peripheral bronchial injuries)
Parenchymal injuries during thoracic exploration for massive hemothorax are managed without resection AMAP.
Peripheral lacerations with stapled wedge resection using a stapler.
Central injuries with pulmonary tractotomy which permites selective ligation of individual bronchioles. Prevents
development of hematoma, air embolism, and reduces need for formal lobar resection.
Injuries requiring pneumonectomy are usually fatal due to right heart decompensation.
Post-traumatic pneumatoceles that can be infected. Benign clinical course usually treated with pain management,
pulmonary toilet*, and serial radiography. If with persistent fever and leukocytosis:
- Chest CT with CT-guided catheter drainage
- 25% of patients do not respond to antibiotic therapy alone
- Refractory cases (i.e. to drainage and antibiotics) may indicate partial resection.
Most common complication after thoracic injury is EMPYEMA.
- Percutaneous drainage
- Fibrinolytics
- Presumptive antibiotics covering MRSA
Esophagus
- If two suture lines are in close approximation, interposition of a vascularized pedicle is warranted to prevent fistula
formation
Chest Wall
- Virtually all CW injuries are treated NON-OPERATIVELY with:
o Pain control
o Pulmonary toilet or ventilatory management
o Drainage of pleural space if indicated
- Epidural anesthesia is reserved for multiple segmental fractures
- Extensive flail chest or markedly displaced fractures
o ORIF can be done
- Chest wall defects – tissue approximation or tissue transfer for convergence
- Scapular and sternal fractures – rarely require operative intervention; marker for significant force; significant
displacement may warrant sternal plating
- Clavicle fractures – often isolated, managed with pain control and immobilization
- Posterior clavicular fracture – may require more intervention due to involvement of subclavian vessels
Diaphragm
- Blunt injuries usually result in linear tear, and usually large
- Penetrating injuries are variable
- Acute injuries are usually repaired through an abdominal approach to manage potential abdominal injuries
- Sequence
o Repair through abdominal approach
o Chest blood evacuation

5. o Thoracostomy tube placement
- Large avulsions may require polypropylene or biologic mesh
Abdominal Compartment Syndrome
- Organ dysfunction due to increased abdominal pressure with compromises perfusion to vital organs
- Normal IAP – 5 mmHg
- IAH HTN – greater than > 12 mmHg
- Abdominal Compartment Syndrome in adults is defined as an intraabdominal pressure of >20 mmHg with
evidence of organ dysfunction.
o In reality, a more relevant definition may be an elevated intraabdominal pressure with evidence of organ
dysfunction. There are no clear values for intraabdominal hypertension or compartment syndrome in children.
- Clinical Presentation
o Tense and distended abdomen
o Worsening oliguria and ventilatory requirements
o Peripheral edema
o Hypotension
o Jugular venous distention
Prolonged and extensive infusion and resuscitation leads to bowel edema and its subsequent compression
- Sepsis, pancreatitis; common in pancreatitis patient
- Increase MAP to overcome resistance of abdominal pressure

6. Life Threatening Penetrating Chest Injuries
- Tension Pneumothorax
- Massive Hemothorax
- Pericardial Tamponade (3D Distant Heart Sounds, Decreased Arterial pressure, Distended Jugular Veins)

7. Tension Pneumothorax Massive Hemothorax Cardiac Tamponade
Hypotension +
causes deviation kinking the
vessels returning to the
heart, lower preload
collapsed lungs
lower vital capacity
+
30% of decrease in blood
volume causes ~ 1.5 L
+
due to restrictive effect of
the cardiac tamponade
Pallor - + -
Neck Vein Engorgement +
Due to decreased venous
return
- +
Distant Heart Sounds
Decreased Arterial pressure
Distended Jugular Veins
- due to congestion
Decreased Breath Sounds + + normal
Heart Sounds audible
dislocated
audible or abnormal muffled
Normal Pressure Outside
760 torr or mmHg
0 cm H2O
Thoracic Cavity in Thoracic Cavity
- depends on inspiration/expiration
- -6 to 9 mmHg interpleural
Management of Tension Pneumothorax
Needle decompression ff. by tube thoracostomy

8. Before decompression
- Flutter valve, 3 corner dressing
- Occlusion of opening
Treatment of tension pneumothorax is immediate needle decompression by inserting a large-bore (eg, 14- or 16-
gauge) needle into the 2nd intercostal space in the midclavicular line.
- Thinnest part of the chest
- More accessible in a supine patient
- Avoids the internal thoracic arteries
Air will usually gush out. Because needle decompression causes a simple pneumothorax, tube thoracostomy should
be done immediately thereafter.
- 3rd or 4th intercostal space, AAL or MAL
- Lower intercostal spaces are wider
- Preferred at lower ICS for this reason
Fully insert the needle, and leave it.

10. Massive Hemothorax Management
- Bleeding stops since the lungs re-expands and puts pressure in injury that resolves bleeding
Operative Treatment
- 300 ml/h for 2 consecutive hours

11. Cardiac Tamponade
Approach Considerations
Cardiac tamponade is a medical emergency that requires urgent drainage of the pericardial fluid. Preferably,
patients should be monitored in an intensive care unit. All patients should receive the following:
- Oxygen
- Volume expansion with blood, plasma, dextran, or isotonic sodium chloride solution, as necessary, to
maintain adequate intravascular volume - Sagristà-Sauleda et al noted significant increase in cardiac output
after volume expansion [24] (see the Cardiac Output calculator)
- Bed rest with leg elevation - This may help increase venous return
Positive-pressure mechanical ventilation should be avoided because it may decrease venous return and aggravate
signs and symptoms of tamponade.
Inpatient care
After pericardiocentesis, leave the intrapericardial catheter in place after securing it to the skin using sterile
procedure and attaching it to a closed drainage system via a 3-way stopcock. Periodically check for re-
accumulation of fluid and drain as needed.
- 45 degrees, pointed to the left shoulder
The catheter can be left in place for 1-2 days and can be used for pericardiocentesis. Serial fluid cell counts can be
useful for helping to discover an impending bacterial catheter infection, which could be catastrophic. If the white
blood cell (WBC) count rises significantly, the pericardial catheter must be removed immediately.
A Swan-Ganz catheter can be left in place for continuous monitoring of hemodynamics and to assess the effect of
reaccumulation of pericardial fluid. A repeat echocardiogram and a repeat chest radiograph should be performed
within 24 hours.
DEFINITIVE - opera
Consultations
Consultations associated with cardiac tamponade can include the following:
Hemodynamically stable patients - Cardiologist
Hemodynamically unstable patients - Cardiologist, cardiothoracic surgeon