Trauma Thoracotomy: Principles and Techniques

Kenneth L. Mattox, Matthew J. Wall, Jr., and Peter Tsai

Chest trauma was documented in the Edwin Smith Surgical Papyrus, written by Imhotep over 5000 years ago.¹ The first recorded operation in the United States was removal of an arrowhead from an Indian’s chest by Cabeza de Vaca in 1635.² The mortality from chest injury during war has ranged from 28.5% during the Crimean War (1853–1856) to a less than 5% today. Currently, in the United States more than 16,000 deaths occur annually as a direct result of thoracic trauma.³

The chest composes almost one fourth of the total body mass and is therefore often subjected to injury during trauma from any etiology. Regardless of etiology, a patient with thoracic trauma requires logical and sequential evaluation of the chest injury, followed by focused therapy, which, in some instances (less than 20% of the time), involves an operation. Those evaluating and treating must understand the anatomy, physiology, and function of each of the thoracic organs, as well as how each decision and treatment will affect outcome. The acute care surgeon must understand thoracic organ responses to and manifestations of various injuries, appropriate evaluation tools, which evaluations might be misleading, redundant, or unnecessary, and approaches to therapy. It is essential to be able to recognize when minor intervention or damage control should be applied to a chest injury condition verses when a formal surgical intervention is indicated. When surgery is performed the surgeon must also understand benefits and limitations of the various patient positions and incisions. Finally, as every evaluation and therapy has its potential hazard or contraindication, the acute care surgeon must understand traditional concepts that are either dated or currently considered controversial.

Injury to the chest and its organs may be caused by penetration (from missiles, fragments, knives, needles, and other objects), blunt forces, iatrogenic misadventure, blasts, ingestion of toxic substances, and, indirectly, from abnormal medical conditions elsewhere in the body. Each of these etiologies has differing initial manifestations as well as evaluation and treatment approaches.^4–6 These differences are more specifically discussed elsewhere in this textbook. This overview chapter contains many cultural views, which have become doctrine and standard use by the authors, but, admittedly, based on Class 3 evidence, which might differ from the culture in other trauma centers.

THORACIC ANATOMY AND PHYSIOLOGY: RESPONSE TO TRAUMA

The thoracic cavity is surrounded by a flexible boney cage, supported by respiratory and locomotive muscles. Three separate compartments house the two lungs with their five segments that are attached by vascular structures to the central cardiovascular compartment. In addition, the trachea and bronchus connect the lungs to the pharynx, and a series of nerves traverse the thoracic cavity. In the healthy patient, the lungs and heart are separated from their surrounding cavities by a smooth fibrous pleural lining. Following inflammation, fusion of these linings may alter some physiology and, consequently, some treatment options. Prior to any procedure following thoracic trauma, the surgeon is well advised to review the regional anatomy, determine position and incision options for a particular technique, and consider all approaches.

Evaluation technology

Significant technology—from simple physical examination to extremely complex and sophisticated imaging and laboratory testing—exists to assist in the evaluation of a patient with pathology in the chest.⁷ Imaging may involve ultrasound, Doppler technology, classic radiologic tests, helical multidetection computerized technology (CT scans), magnetic resonance imaging (MRI), and others. Other tests available to the surgeon include cardiologic evaluation using EKG, echocardiogram, and even cardiac catheterization. Hematologic, clotting, and metabolic testing, as well as pulmonary function testing are other potentially helpful adjuncts. Endoscopic evaluation of the trachea and esophagus can supplement imaging modalities.

In deciding which evaluation tools to use, first consider what you expect the test to demonstrate and, then, consider how the results will alter decision-making or treatment. Once these questions are considered and answered, the treating physician may well decide the tests are not needed. It is always helpful to have a progress note reflecting the decision-making process—tests ordered/why/why not—in the patient’s medical record.

TUBE THORACOSTOMY

Tube thoracostomy is both the most common procedure performed following chest trauma and also one of the most misunderstood and underrated operations in medicine. It is the only invasive procedure that most (>85%) of patients with chest injury will require. Upward of 25% of patients with chest tubes will encounter some difficulty with malposition, connection problems, collection system difficulty, pressure abnormalities, or misperceptions and complications at the time of removal. Often, such difficulty can and does result in a clotted hemothorax that is not evacuated, a pleural space problem, a retained pneumothorax, or a recurrent pneumothorax. Far too often, second and multiple chest tubes are unnecessarily inserted as a result of a misunderstanding of the function and technique of tube thoracostomy.

Tube thoracostomy following trauma should be accomplished in as pain and complication free manner as possible. Trocar-tipped chest tubes should be avoided. Chest tubes are best inserted in the area of the auscultatory triangle in the mid-axillary line near the 4th or 5th intercostal space. Subcutaneous tissue and muscular dissection may be accomplished with clamps or dissecting scissors, but the pleura should be opened with an exploring finger, not a sharp instrument. Care is taken to avoid injury to the intercostal vessels and nerve on the under surface of each rib, as such injury can produce iatrogenic bleeding and pain. Following a gentle digital exploratory thoracotomy, an appropriately sized chest tube (32–36 French) is directed toward the back and apex of the pleural space and attached to an appropriate collection device. This insertion site overlies the major pulmonary fissure. Care must be taken to assure that the chest tube is not in this fissure, the exact relative location of which can often be ascertained by preinsertion digital exploration. One might consider antotransfusing fresh hemothorax blood using an appropriate device.

INDICATIONS FOR THORACOTOMY FOLLOWING TRAUMA

Only approximately 15% of patients with chest injury require a formal thoracotomy. The indications for thoracotomy continue to change as newer, noninvasive therapies such as endovascular removal of intravascular foreign bodies and endovascular stent graft insertions become available. Although many different injury patterns may occur in the chest and to its contents, indications for an acute formal thoracotomy follow both anatomic and physiologic parameters and include:

• Loss of chest wall substance (traumatic thoracotomy)

• Traumatic hemopericardium⁸

• Evidence of free wall, septal, or valvular cardiac disruption⁸

• Radiologic or endoscopic evidence of tracheal, bronchial, esophageal, or great vessel injury^9,10

• Greater than 1500 mL blood loss from the pleural cavity following the initial tube thoracostomy¹¹

• Greater than a sustained 200 mL continuing blood loss per hour from the tube thoracostomy

• Loss of cardiac function or proximal vascular control (resuscitative thoracotomy)^9,12–15

• Massive air leak

• Demonstrable thoracic tracheal or bronchus injury

• Uncontrolled hemorrhage in thoracic outlet major injury

• Mediastinal missile traverse with massive blood or air loss through the chest tube

• Removal of selective foreign bodies

• Massive air embolism, particularly systemic air embolism

• Retained clotted hemothorax (subacute and chronic indications)¹⁶

• Posttraumatic contained empyema¹⁶

• Cardiac herniation (ruptured pericardium)¹⁷

• Cardiac septal or valve disruption

MINOR THERAPEUTIC INTERVENTIONS

In addition to the routine basic maneuvers to stabilize the trauma patient, a number of minor therapeutic interventions are available. Some, such as needle decompression of the pleural cavity, pericardiocentesis, interosseous sternal fluid infusions, and subxyphoid pericardiotomy, have been controversial with regard to specific indications and the ultimate expected benefit. Specific, evidence-based data are not sufficient to recommend these maneuvers. Other minor thoracic maneuvers used by the surgeon include:

• Endotracheal intubation (limiting the ventilatory pressures to less than 40 TORR in order to prevent systemic air embolism

• Intercostal tube thoracostomy

• Video-assisted thoracic surgery (VATS)

• Intercostal and epidural block for pain control

• Digital thoracotomy (gentle digital exploration to the extent of the inserted finger at the time of tube thoracostomy)

PATIENT POSITIONS/INCISIONS

The supine position is the utility position for operations on thoracic trauma patients, as it allows for a variety of anterior incisions, including median sternotomy, right and or left anterolateral thoracotomy, transternal bilateral anterolateral thoracotomy, and partial anterior incisions (Fig. 24-1).

FIGURE 24-1

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