The previous chapter describes in detail how you should approach chest injuries in combat trauma and the choice of incisions. The main point that cannot be repeated often enough is that you should almost always be approaching these injuries through an anterolateral thoracotomy or median sternotomy , with the patient supine. Inexperienced trauma surgeons use “elective” surgical approaches aimed at maximizing ease and exposure at the expense of flexibility and options. A good combat surgeon will accept less-than-perfect (although always adequate) exposure to maintain the maximal amount of flexibility and options. If you break this basic rule, then you will inevitably end up with the patient in a lateral decubitus position when you realize that the bleeding is actually coming from the abdomen, the mediastinum, or the other side of the chest. You can do everything you need to do through an anterolateral thoracotomy  – just make sure your incision is long enough, and you have adequate self-retaining retraction. Rapid entry into the chest can be obtained with one or two aggressive swipes of the scalpel through skin, fat, and muscle followed by wide opening of the remaining intercostal muscle fibers and pleura using heavy scissors. The best and most underutilized maneuver to improve exposure is to extend your skin incision medially for 5–10 cm onto the opposite chest and divide the sternum. Now that you’re there, establish your priorities and get to work.

Just like a combat trauma laparotomy , a damage control approach should be your default when operating on major traumatic lung injuries in the combat setting. Do what needs to be done immediately and what the patient will tolerate, and then get out to finish the fight another day. But that is where the similarities to abdominal damage control end. In the abdomen the only immediately life-threatening concern you need to focus on is controlling hemorrhage. This is usually not the case in the chest. Tension pneumothorax , cardiac tamponade, arrhythmias, refractory hypoxia or hypercarbia, and the dreaded air embolus are all quick and silent killers that need to be on your mind and rapidly addressed or prevented. Close coordination with your anesthesia provider in these cases is of the utmost importance, particularly in the setting of lung injury. Do not waste time trying to get a double lumen endotracheal tube or bronchial blocker in perfect position before starting the operation – you will usually lose much more than you gain, and it can wait until you have bleeding controlled. Some simple manipulations of the tidal volume and respiratory rate or positioning of the endotracheal tube (i.e., advanced to right mainstem) can make your life a whole lot easier and get the inflated lungs out of your way. An additional useful maneuver is to have the anesthesia provider disconnect the patient from the ventilator after full exhalation, compress the deflated lung with packs and a hand-held or self-retaining retractor, and then reinitiate mechanical ventilation. This will give you almost the equivalent of single-lung ventilation.

Just like in the abdomen, hemorrhage control is goal number one. Packing is not the first maneuver, particularly when the chest is full of blood! Rapidly scoop out the clot with your hands, and then use some dry lap pads and suction to remove the remainder of the pooled fluid. Now assess the hemorrhage and determine if the bleeding can be easily controlled with manual compression or clamping – if so, proceed with definitive control. If you have large volume hemorrhage or bleeding from multiple sites then go ahead and pack the cavity, make sure your anesthesia provider is catching up and ready for more bleeding, and then begin pack removal and hemorrhage control. If the volume of bleeding is too great to allow for packing to assist in visualization, use your fingers as a clamp to occlude the main pulmonary artery and vein at the hilum while an assistant works on using sponges and a sucker to clear out the blood. If no assistant is available a large vascular clamp can replace your fingers to accomplish the same goal. At this point you can gradually release the hilar vessels to better localize the bleeding source. A kidney pedicle clamp is commonly available in the field and can be used, although a larger, more gently curved, and less traumatic clamp (if available) is a better choice. Adequate exposure, retraction, and packing of the lung, and strong suction are your best allies for localizing the bleeding and obtaining control.

In addition to hemorrhage, you must also consider and address the several other quick killers listed above. Opening the chest has removed the possibility of any tension physiology on that side, but don’t forget about the contralateral chest . Be liberal about putting in a chest tube on the other side to rule out significant bleeding or pneumothorax . If you are using a median sternotomy, you can incise both pleura and open them widely with your fingers. If you are faced with life-threatening hypoxia or hypercarbia, then quickly look for a potentially treatable source such as a massive air leak from lung parenchyma or an injury to the proximal airways. Maximize ventilation of the normal lung by advancing the endotracheal tube to mainstem the opposite airway, placement of a bronchial blocker, or a double lumen tube. All of these take some time, so try to control the air leak by clamping the lung or airway proximal to the site of injury. This may entail clamping the entire lung hilum for a very proximal injury, even using your fingers as a clamp initially as described above. Alternatively, if you have good exposure and visualization, you can rapidly suture the injury and return later for definitive repair. For proximal airway injuries, use absorbable suture such as PDS or Maxon in case your rapid repair turns out to a durable one.

Don’t forget about air embolism ! It is a relatively common and often unrecognized killer in patients with a large pulmonary laceration who have the potential for air entry into the pulmonary venous system. There are several things you can do to minimize the chance of an air embolus: rapid control and compression of the injured lung segment, proximal pulmonary hilar clamping, low-pressure ventilation until the injury is controlled, and submerging the injured area under saline. If your patient experiences sudden cardiac decompensation with no other obvious source, then air embolism should be assumed, and you can follow the management principles outlined in the next section.

Performing a damage control closure of the thoracic cavity can be more complicated than the abdomen. Simply packing the cavity and closing is usually not an option, particularly when there is bilateral lung injury and the patient won’t tolerate complete compression of one lung. Other factors you must consider are creating a tension pneumothorax or tamponade by closing the cavity without adequate drainage, and maintaining some degree of normal respiratory or chest wall mechanics. In any chest closure, you must leave adequate large-bore chest tube drainage. In general, nothing less than two 32F tubes is adequate after a trauma thoracotomy , especially if transport out of theater is in the patient’s near future. My preferred temporary closure is using a large monofilament suture incorporating muscle, fascia, and skin in an en masse running and locked closure. This will create a tight closure and control bleeding from the wound margins better than a skin-only closure. Rapid skin-only closure can also be performed with a running suture, staples, or towel clips. Alternatively, the wound can be closed without suture by manually holding the wound edges together and applying a large Ioban dressing . Ioban is also useful in a complex incision that doesn’t come together adequately, and there is concern for air leak. Don’t forget bleeding from your incision! The chest wall musculature, intercostals vessels, and internal mammary arteries will all bleed significantly if not properly assessed and controlled before leaving the OR.

Pneumothoraces are relatively common and Hemothorax in combat trauma, although the isolated pneumothorax without an associated hemothorax or other significant chest injury is much less common than in civilian trauma. Physical exam diagnosis is often difficult, particularly in the noisy and chaotic trauma bay. You should familiarize yourself with the simple and highly reliable technique for ultrasound diagnosis of a pneumothorax (see Chap. 6) as you may not have x-ray immediately available. You will see many patients arrive with needle catheters placed in the field – these are often placed unnecessarily and frequently never actually penetrate into the thoracic cavity. You are not automatically obligated to place a chest tube – assess the patient and if their pulmonary status is stable, remove the needle and do your ultrasound or chest x-ray. If there is associated blood, then a large-bore chest tube placed in the standard fashion (posteriorly to the apex) is appropriate. If it is an isolated pneumothorax then you are often better off placing a smaller tube in a more anterior position and guiding it along the anterior chest wall to the apex.

Hemothorax in combat injuries should raise your concern for associated severe intrathoracic injuries , continued bleeding, and the possible need for an operation. While the majority of civilian hemothoraces can be managed with tube thoracostomy only, we have found that to be much less successful in the combat setting. Always remember the limitations of your surroundings – the trauma bay in any forward deployed facility is a highly contaminated, crowded, and unsterile environment that is not optimized for procedures. You will also not have VATS available to easily manage problems like a retained hemothorax or empyema. If your patient has a significant hemothorax that requires chest tube drainage, then the best place to do that is in the controlled and more sterile environment of the operating room. Prep and drape the entire chest so you are ready to convert to an open thoracotomy or sternotomy if needed. If you make your chest tube incision slightly larger than usual (2–3 cm is fine), you can pass a large suction catheter (Poole suction) into the chest to thoroughly evacuate the blood and perform large volume irrigation prior to placement of the chest tube. Then a large-bore chest tube can be easily placed and secured, and the patient transferred to either the ward/ICU, or evacuated to the next echelon of care.

Injury to the lung parenchyma will be the most common problem you will face when operating in the chest. Fortunately, it is usually not difficult to quickly identify the exact area of injury and to gain at least temporary control of bleeding. The injured area will typically demonstrate continuous low-volume bleeding and will likely also have a visible or audible air leak. The first instruments you should be sticking into the chest to control bleeding should always be your hands. Simple bimanual pressure on the injured area is usually sufficient to control bleeding and will also improve handling by compressing air out of the lung tissue. It may also be helpful to have the anesthesia provider lower the tidal volumes or advance the endotracheal tube to mainstem the opposite bronchus to facilitate exposure. Even with both lungs being fully ventilated, you can collapse the ipsilateral lung by applying gradual and continuous pressure during exhalation with laparotomy pads and then maintain the exposure with a self-retaining retractor or with an assistant maintaining compression of the deflated lung.

Normal lung tissue is relatively fragile, so injured lung tissue is extremely easy to tear or disrupt with improper or overly aggressive handling. Use only your hands initially to expose the lung and compress the area of hemorrhage. Grasping and retracting the lung is aided by using a small lap pad or gauze for traction, but do not pull the tissue perpendicular to the injury as this will enlarge the parenchymal disruption and worsen the air leak. Duval lung clamps are available in the field and can be a useful adjunct when manipulating the lung. Additionally, using Duval lung clamps to temporarily oppose injured lung tissue can control the air leaks initially and free your hands to continue exploring the chest and deal with more urgent matters.

After you have adequately controlled hemorrhage and assessed parenchymal injuries, you must decide on the most expedient and complete method to control air leaks while at the same time preserving lung tissue (Fig. 15.1). Young, healthy soldiers will tolerate a significant amount of lung tissue loss, so do not be worried about large stapled wedge resections. The choice of staple load will depend on the thickness of the tissue to be divided; however, staples with a depth of 3.5–3.8 mm in a linear stapler (this translates into a blue or gold Ethicon GIA load) are good choices that work in all situations. For missile wounds through the lung tissue, a stapled tractotomy (Fig. 15.2) may be an adequate method to initially control air leaks as well as get to the source of bleeding. One arm of the stapler is placed through the missile tract, and the lung above the tract is divided. You may need more than one load to accomplish the above goals. Inspect the opened missile tract and ligate large vessels and air leaks with suture as needed. Pneumonorraphy, or oversewing of the entrance and exit wounds, should be avoided. You may not have an appropriate stapler or staple loads, so an alternative is to use clamps to secure and divide the tract (Fig. 15.3), and then oversew each side of the divided lung parenchyma.