Emergency War Surgery NATO Handbook: Part IV: Regional Wounds and Injuries: Chapter XXVIII: Wounds and Injuries of the Chest

Management at the Surgical Treatment Facility

United States Department of Defense

Emergency life-saving interventions may be necessary in casualties evacuated directly from the battlefield. However, more often than not, the important problem facing the surgeon will be to decide whether an operation beyond simple soft tissue wound care is indicated. The most common reason for performing a thoracotomy is massive or persistent bleeding. Since bleeding from most missile wounds of the lung parenchyma will stop when the lung is expanded, thoracotomy is seldom required. However, with the advent of more potent small arms, the surgeon is likely to encounter casualties with grossly destructive wounds of the lung, wounds which will not stop bleeding without surgical intervention. As a general rule, hemorrhage from chest wall arteries will require surgical ligation. Casualties with wounds of the heart or great vessels are much less common, constituting only 2-3% of the total thoracic population who survive to be evacuated from the battlefield.

The following are useful indications for performing a formal thoracotomy:

1. An opacified hemithorax on X-ray.

2. Initial drainage of 1,500 ml of blood followed by 500 ml or more in the next hour.

3. Drainage of 200-300 ml of blood per hour for more than 4 hours.

4. Massive airleak with continuous bubbling throughout the respiratory cycle.

5. X-ray evidence of massive pulmonary contusion or hematoma, with clinical and laboratory evidence of a life-threatening shunt or airway compromise secondary to pulmonary bleeding.

6. Physical signs of pericardial tamponade or suspicion of tamponade or shock, and X-ray evidence of a missile in proximity to heart.

Suspected wounds of the lungs are best approached through a formal posterior lateral thoracotomy made through the fifth or sixth interspace. Wounds of the heart are best approached through an anterior thoracotomy made in the fifth intercostal space on the side of the missile wound with extension across the sternum if necessary. A median sternotomy is less often employed if for no other reason than that appropriate instruments to divide the sternum may not be available A pericardiocentesis should not be used as an alternative to thoracotomy. The need to be constantly vigilant for signs of recurrent tamponade, and the possibility that the operating room will have been preempted by a mass casualty situation just when it is obvious that conservative management has failed, speak against pericardiocentesis in a combat zone hospital.

Although it is usually said that the casualty should have received optimal resuscitation (correction of hypovolemia and acidosis, etc.) prior to going to the operating room, from the practical standpoint this is frequently not possible because operation is required for resuscitation. All thoracotomies should be done under general anesthesia with controlled positive pressure ventilation through a secure airway. Intracoperative management will usually involve debridement of partially detached lung, ligation of bleeding vessels, and oversewing of lacerated lung. If airleaks persist, if the parenchyma of one or more lobes has been shattered, or if the anesthetist reports persistence of copious tracheobronchial bleeding, a formal resection should be considered, Although unusual, there are case reports of life-saving lobectomies and pneumonectomies given such circumstances. Chest closure should follow standard practice. At least two chest tubes should be inserted, one high and anterior and one low and lateral. Antibiotic coverage, starting before the incision is made, is essential.

Wounds of the heart seen at operation are usually small, and hemorrhage can be controlled by digital pressure while bolstered mattress sutures are inserted. Care should be taken not to incarcerate an epicardial coronary artery in the suture; the suture can always be placed deep to the artery. A rare casualty will have a wound of an epicardial artery. Given the nonavailability of cardiopulmonary bypass, there is no alternative but to ligate the vessel and hope for the best.

Large open wounds of the chest wall require debridement and airtight closure of the musculofascial layer. Rib fragments should be removed and rib ends smoothed to prevent subsequent laceration of the lung. It is frequently possible to evaluate the lung and to evacuate the pleural space by extending the wound defect. Thus the casualty is spared a formal thoracotomy. This fact helps explain why fewer 20% of thoracic casualtie's have formal thoracotomies; many have de facto minithoracotomies as part of their chest wall wound management.

Clotted hemothorax and infected hemothorax are complications which may become apparent prior to evacuation from the combat zone. A clotted hemothorax should be surgically removed if it is less than 7-10 days old. Beyond that time, thoracotomy should be delayed for 4-5 weeks, after which a pleural decortication should be performed. During the decortication, care should be taken when performing the dissection where the parietal pleura reflects onto the lung posteriorly. If this "corner" is not turned properly, the dissection may enter the aorta or esophagus. The same problem exists when the dissection is carried into the diaphragm. If the procedure is delayed for months, the problem will be a trapped lung. Decortication is indicated if more than the equivalent of one lobe is nonfunctional. An infected hemothorax cannot be removed by tube drainage and will require decortication at whatever time it becomes apparent. Retained foreign bodies should be removed electively if they exceed 1.5 cm in size. Notwithstanding the experience of World War II, intracardiac foreign bodies should not be removed unless cardiopulmonary bypass is readily available.

Penetrating combat trauma involving the esophagus or trachea is rare. There is suggestive evidence that small penetrating injuries, especially of the membranous trachea, maybe benign. If pneumo-mediastinum is apparent on X-ray, bronchoscopy is indicated. If no wound is apparent, observation is indicated. When an esophageal wound is found at the time of thoracotomy performed for bleeding, more often than not a gross defect is found which can be treated only by defunctionalization. Use of a gastric patch to close a low esophageal. war wound has been described. Another rare manifestation of penetrating chest trauma is post-traumatic pneumatocele. Lungs tolerate the temporary cavity produced by a high-energy transfer missile with much less damage than do solid parenchymal organs, such as the brain and liver, but occasional casualties will be seen who develop a cyst around the permanent tract. This should occasion some concern because such post traumatic cysts may become infected or be the site of massive hemorrhage. If they do not promptly regress, they should be excised.

About 20% of the casualties with wounds of the trunk will have penetrating injuries of both the chest and abdomen. In about 50% of these casualties, the same missile is responsible for both components. Experience has shown that the abdominal component usually has the greatest injury severity, and that adequate treatment consists of laparotomy and insertion of a chest tube. The surgeon must not neglect to close the perforation of the diaphragm.

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Operational Medicine 2001

Health Care in Military Settings

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