European Journal of Trauma and Emergency Surgery Focus on Solid Organ Injury

Cardiac and Pulmonary Injury George C. Velmahos, Muhammad U. Butt1

Abstract symptoms of PCI, followed by expeditious surgical Cardiac and pulmonary injuries present major chal- intervention, are extremely important [2, 3]. lenges in diagnosis and treatment. Distinct differences between penetrating and blunt trauma of these or- Diagnosis gans exist. Outcomes for severe injuries are still grave. Initial Assessment Organized trauma systems can provide optimal care Penetrating cardiac injury typically presents either by by minimizing prehospital time, allowing easy access signs of or hypovolemia (or some to imaging modalities, and offering state-of-the-art combination of the two) [4]. The diagnosis of PCI and treatment strategies. A multidisciplinary approach, the decision to operate are mostly clinical; delays for including surgeons, intensivists, and others, is abso- imaging or other tests are usually detrimental and lutely necessary. possible only in self-selected patients who are not agonal. Beck’s triad is the classic presentation for car- Key Words diac tamponade, but occurs only in 41% of the patients Cardiac trauma Æ Pulmonary trauma Æ Blunt [5]. It consists of jugular venous distention, hypotension trauma Æ Penetrating trauma Æ Gunshot wound and muffled sounds. A patient with a precordial Abbreviations: PCI: Penetrating cardiac injury; GSW: stab wound who is hypotensive, diaphoretic, confused, Gunshot wound; CXR: Chest X-ray; EKG: Electrocar- and agitated (due to brain hypoperfusion), is the clas- diogram; FAST: Focused assessment with sonography sically described picture of PCI. It should be remem- for trauma; ER: Emergency room; OR: Operation room; bered that frequently, there is open communication CPR: Cardio pulmonary resuscitation; BCI: Blunt car- between the heart wound and the pleural cavity diac injury; MVA: Motor vehicle accident; ICU: Inten- through a pericardial hole, which allows into sive care unit; PLI: Penetrating injury; NPV: the chest and relief of the tamponade. Under these Negative predictive value; CT: Computed tomography; conditions the patient is more likely to present with VATS: Video-assisted thoracoscopic surgery; ARDS: signs of hypovolemic shock rather than tamponade Adult respiratory distress syndrome physiology. Chest radiographs (CXR) are of limited value although a globular heart or a missile overlying the heart shadow could offer valuable information. Eur J Trauma Emerg Surg 2008;34:327–37 However, a normal pericardial appearance on CXR DOI 10.1007/s00068-008-8099-4 carries little negative predictive value, as an injury may surely exist. At least 250 ml of pericardial fluid is re- quired to detect heart enlargement on CXR. Pneumo- Penetrating Cardiac Injury pericardium is neither common nor pathognomonic. Background Demetriades et al. in a study of 20 PCI patients with Penetrating cardiac injury (PCI) is caused by gunshot pneumopericardium concluded that its presence is not wounds (GSW) in 32–70% of the cases in the USA, an absolute indication for surgery, and that the final although stab wounds are more frequent in other decision should be based on clinical presentation [6]. countries. Although less than 10% of patients with PCI An electrocardiogram (EKG) may show decreased arrive at the hospital alive [1], for those who do there is QRS voltage (cardiac tamponade) or ST segment ele- a significant likelihood for survival. Time is of the es- vation but a normal EKG does not rule out a cardiac sence, and immediate recognition of the signs and injury. The use of transthoracic echocardiography,

1 Division of Trauma, Emergency Surgery and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, MA, USA.

Received: June 17, 2008; revision accepted: July 2, 2008; Published Online: July 25, 2008

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performed by a surgeon or emergency medicine phy- laparotomy incision. After the abdominal injuries are sician as part of a focused assessment with sonography packed to control bleeding, the central tendon of the for trauma (FAST), is considered highly accurate for diaphragm and then the pericardium are opened to with a specificity of 99.3%, sensitivity detect a cardiac injury and prioritize the sequence of of 100%, positive predictive value of 87% and negative surgical interventions in the chest and abdomen. predictive value of 100% [7]. Rozycki et al. [8], have also reported 100% sensitivity and 96.9% specificity Management among 261 patients with penetrating thoracic injuries. Some general principles of management can be stan- However, despite these optimal results, which are dardized according to the five types of patients with produced by highly trained experts, FAST remains PCI, as grouped according to clinical presentation. operator-dependent and often unreliable. Multiple Controversies and recommended management are investigators, with adequate training and trauma vol- described in table 1. These groups do not include all umes, have shown that the true sensitivity and speci- the variations in which PCI patients can present. ficity of FAST is probably lower than what was initially reported [9, 10]. In a study of 372 patients Miller et al. Prehospital Management [9] demonstrated that FAST had a sensitivity of 42% Most patients experiencing PCI die before reaching the and specificity of 98%. Similarly, in another study of 75 hospital. Paramedics play a critical role in those who patients Udobi et al. [10] also showed that FAST had a survive. There is controversy about the role of prehos- sensitivity of 46% and a specificity of 94%. Formal 2D pital endotracheal intubation. Although this interven- echocardiography performed by a radiologist may im- tion may be reasonable in a patient who is losing all prove the accuracy, but takes longer and – most vital signs and is at risk of brain anoxia, the best reac- importantly – is rarely available when trauma occurs, tion by the paramedics is to waste no time for any i.e., off regular working hours. intervention and to try to shorten the prehospital time Pericardiocentesis as a diagnostic tool is mentioned to an absolute minimum. No endotracheal tube can only to be condemned. The insertion of a needle in the reverse the bleeding from a cardiac hole. The only life- narrow pericardial space will only serve to injure the saving intervention on a PCI patient is the relief of heart and produce hemopericardium, if it does not al- tamponade and control of bleeding [12], interventions ready exist. A pericardial window is of limited value in which cannot usually be offered in the prehospital the era of echocardiography. A vertical incision is environment. The same principles apply for intrave- made under the xiphoid extending for a few centime- nous line placement. If this can be performed rapidly, ters toward the umbilicus. The linea alba is opened and preferably during transport, then it may be of value. But the preperitoneal space entered with attention to avoid it should in no way delay the process. The value of fluid opening the peritoneum inadvertently. By dissecting resuscitation is controversial. In a study of delayed the preperitoneal fat inferiorly, the heartbeat is rec- resuscitation, patients with penetrating torso injuries ognized and the diaphragm opened at that point. Then randomized to receive fluid resuscitation after opera- the pericardium is opened. Care must be taken to tive bleeding control had improved survival compared isolate the area from surrounding bleeding from tissues to those randomized to full fluid resuscitation during because it is essential to inspect carefully the color of the prehospital and in-hospital preoperative phase [13]. the fluid which exits the pericardial sac upon opening. We believe that there is more benefit than risk to forego or blood-tinged fluid indicates a cardiac injury line insertion in order to gain valuable time and reach and the operation continues with a sternotomy. Al- quickly to the place of definitive care, i.e., the hospital. though this technique was useful in the past, there are only a few reasons to do it today. If a patient is stable Emergency Room Management enough to be taken to the operating room simply for If the patient is hemodynamically stable upon arrival, a diagnostic purposes, then the patient can afford the detailed evaluation, CXR, FAST, and possibly a for- time for a detailed echocardiogram, which is noninva- mal echocardiography are in order. Fluids should be sive and highly accurate. A pericardial window is still kept under control, as it is easy to allow indiscrimi- of value when performed as an emergency procedure nately high volumes to be infused in short times, con- in a patient taken to the operating room for a lapa- verting a clotted perforation to a gushing wound. rotomy. On these patients, who have abdominal inju- Similarly, it is important to avoid anxiety- and pain- ries and a possible coexisting cardiac injury, the provoking procedures, which may raise the patient’s window is performed transperitoneally through the blood pressure with the same results. At the other end,

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Table 1. Classification and management of penetrating cardiac injury [11].

Category Clinical presentation Main controversies Recommended management

Category I: lifeless No vital signs Whom to resuscitate? Exclude patients with no signs of life for more than 10 min – offer ER thoracotomy for most others Category II: critically unstable Profound hypotension Pericardiocentesis? Rarely recommended, unless prompt surgical intervention is impossible Where to operate? Preferably in the operating room but ER thoracotomy is an option Category III: cardiac tamponade Hypotension and raised central What investigation? Chest radiography (at most) venous pressure Category IV: thoracoabdominal injury Dominated by the abdominal injury How to diagnose? Transdiaphragmatic pericardial window Category V: benign presentation Precardial wound and high index How to diagnose? Echocardiogram – subxiphoid pericardial of suspicion window is an option Whom to treat? The majority of patients although carefully selected patients can be observed

Copied with permission and revised from [11] patients with no vital signs should have an emergency After opening the sternum, the pericardial sac is room (ER) thoracotomy, if the lifeless period is esti- incised and cleared of blood. Surprisingly, a laceration mated to be short or – even better – if the cardiore- to the heart may be mildly or not at all bleeding. In case, spiratory arrest was witnessed at the trauma bay. A of active bleeding direct digital compression should be much harder decision must be made for patients who applied for temporary control. Sutures (3-0) are placed are hemodynamically unstable but are still alive. The and tied. We rarely use pledgets except for complex level of hypotension, the readiness of the operating stellate lacerations or atrial lacerations in elderly pa- room (OR) team, and the distance of the ER to the tients with friable thin walls. Lacerations close to a OR among others are significant factors that may coronary vessel are sutured by horizontal mattress su- influence the decision to run to the OR or open the tures that travel under the vessel. Lacerations of the chest in the ER. An ER thoracotomy requires expe- posterior side of the heart are hard to manage because rience and perfect performance to harvest the small the heart becomes arrhythmic, bradycardic, and even- percentage of success. The chest is opened across the tually arrests when elevated. However, we have found fourth or fifth intercostal space with a few strokes of that gradual elevation by placing gauzes behind the the scalpel. The ribs are spread by a retractor and the heart is better tolerated and can create adequate pericardium is opened as close to the midline as pos- working space for sutures to be placed safely. It is ex- sible to avoid injury to the left phrenic nerve. The tremely rare that cardiopulmonary bypass is required at tamponade is released and the perforation is sutured or the acute phase, and we have used it only once in the even stapled for temporary closure. Clamping of the last 15 years. Internal injuries (valves, septum, chordae) aorta can be done only after control of the cardiac should always be suspected although infrequently injury and if the patient remains profoundly hypoten- requiring immediate repair at the first operation. A sive. Extension of the left thoracotomy toward the postoperative echocardiogram is necessary for diagno- right side (clamshell incision) should be liberally done sis and management plan at a later stage. if access to the injury is compromised through the existing incision. In this case, clamping of the internal Outcome thoracic arteries is indicated, as they are transected Patients who reach the OR without requiring ER routinely during the incision of the sternum. thoracotomy have a favorable outcome [14]. In a study of 373 cardiac wounds, predominantly from Surgical Management stabbings, Velmahos et al. demonstrated the overall If the patient is in extremis, left antero-lateral thora- mortality to be 19%. In the same study, mortality cotomy is performed with possible extension to the rates for stabbing alone (310 patients) was 13%, controlateral chest. For all other conditions, a median whereas, the mortality rate in the GSW group (63 sternotomy is the procedure of choice. patients) was 51% [2]. In another study of 60 patients

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with PCI, Asensio et al. showed an overall mortality Reliable detection, however, is challenging, as there is of 63%. Mortality rates for GSW and stab wounds still no ‘‘gold standard’’ diagnostic criteria for BCI. were 86 and 32%, respectively. The authors con- cluded that parameters measuring physiologic condi- History and Physical Examination tion, cardiovascular-respiratory score component of Details about the trauma event and assessment of the trauma score, and mechanism of injury plus initial cardiac history, particularly beta blockers and calcium rhythm were significant predictors of outcomes in PCI channel blockers, are essential pieces of information. [15]. In a retrospective review of 302 PCI patients The most common presenting symptom is chest pain Tyburski et al. demonstrated that GSW and stab [19]. One-third of patients with BCI have chest wall wound had mortality rates of 77 and 42%, respec- bruising [20]. Fractures of sternum, clavicle, or anterior tively. In the same study, of the 152 patients with an ribs indicate a high impact on the precordial area. The ED thoracotomy, 93 patients had GSW and none FAST exam is not reliable for BCI, since a hemoper- survived; of the 59 with stab wounds, 12 (20%) sur- icardium is only infrequently associated with this vived, whereas, of the 150 patients having an OR injury. thoracotomy, 111 (74%) survived. The authors con- cluded that the physiologic status of the patient at Electrocardiogram (EKG) presentation, mechanism of injury, and presence of a An EKG should be performed in all patients with a tamponade were significant prognostic factors in PCI suspected diagnosis of BCI [21]. The most common [14]. Single-chamber injury to the heart with hemo- finding is sinus tachycardia, followed by premature dynamic stability, shorter duration of cardio-pulmon- atrial or ventricular contractions. Several prospective ary resuscitation (CPR) before arriving at the studies have demonstrated that if the admission EKG hospital, successful intubation, and younger age are in a hemodynamically stable patient displays normal all factors associated with better outcome [15]. sinus rhythm, then the risk of developing cardiac complications related to BCI is extremely small [22, 23], thus the pursuit of diagnosis should be terminated. Patients with abnormal EKGs should be continuously Background monitored for 24–48 h. Blunt cardiac injury (BCI) involves a wide range of myocardial lesions resulting from seven categories of Cardiac Enzymes force: (a) direct, (b) indirect, (c) bidirectional or Neither creatine kinase MB (CK-MB) nor troponin T compressive, (d) decelerative, (e) blast, (f) concussive, is accurate predictors of BCI. Troponin I is the only and (g) combined [16]. The most common cause of BCI marker for myocardial injury not re-expressed in is motor vehicle accident (MVA), accounting for 81% skeletal muscle. In a study by Salim et al. [24], the of cases, followed by crushing injuries (5.7%), falls combination of EKG and troponin I had a negative from a height, acts of violence, and sporting injuries predictive value of 100% for ruling out clinically sig- [17]. The incidence of BCI in all blunt thoracic trauma nificant BCI, defined as hypotension, arrhythmia, or patients is approximately 20–76%. BCI usually pre- cardiac anatomical defect related to the injury. sents with multiple body injuries. In order of fre- quency, the following injuries are associated with BCI: Echocardiography head injury, rib fracture, extremity injury, , Echocardiography detects cardiac motion abnormali- sternal fracture, , aortic or great ties, but cannot be used as a screening test because it is vessel injury, , abdominal injuries, and not immediately available in many institutions and the flail chest [18]. diagnostic yield is relatively low. Karalis et al. have expressed that the value of transthoracic echocardiog- Diagnosis raphy in blunt chest trauma is limited, because patients Initial Evaluation with severe chest wall injury often have difficult The diagnosis of cardiac injury can be difficult in the examinations. Transesophageal echocardiography can multiple trauma patients due to the presence of other provide better quality images compared to transtho- bodily symptoms that can mask those of the injured racic echocardiography. Any of the two tests is indi- heart. Significant BCI is associated with a high level of cated to evaluate cardiac function in a patient with mortality. A heightened level of suspicion and early dysrhythmia, unexplained hypotension, or evidence of identification of BCI is, therefore, of utmost importance. cardiac failure [25].

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Other Diagnostic Modalities by ventricular, and conduction defects. In the Radionuclide angiography has not shown to be supe- meta-analysis of 2,210 patients with BCI, Maenza rior to echocardiography. Pericardiocentesis, as a et al. [28] showed that 2.6% BCI patients develop diagnostic modality, has been supplanted by the use of arrhythmias requiring an intervention. Treatment ultrasound. Other modalities have been investigated to options include the use of antiarrhythmics and/or evaluate BCI, but their potential utility is still unde- electrical cardioversion. The use of CPR and pre- fined. These modalities include Thallium-201 scintig- hospital automatic external defibrillator use has raphy, Technitium-99 m scintigraphy, single photon been shown to increase survival rates in patients emission CT (SPECT) scans, radionuclide multigated that develop ventricular fibrillation due to mycor- acquisition (MUGA) blood pool imaging, and an- dial concussion [29]. timyosin scintigraphy. (3) BCI with cardiac failure: Shultz et al. [18] showed that 2–20% of BCI patients present with signs of Management cardiac failure. The blunt thoracic injury causes Management is dictated by the hemodynamic instability myocardial contusion which results in cellular caused by BCI. El-Chami et al. [26] divided the man- necrosis and inflammatory changes, which alters agement of BCI patients according to the severity of the ventricular compliance and decreases coronary injury into minor, moderate and severe. The author perfusion. BCI patients with signs of cardiac failure proposed that severely injured BCI patients warranted should be admitted to the ICU and managed with management in the intensive care unit (ICU) where intubation to prevent hypoxemia, crystalloid infu- hemodynamic and cardiac rhythm is closely observed. In sion and vasopressors should be given to maintain BCI patients with minor injuries and low clinical suspi- systolic blood pressure of 90 mmHg, and inotropes cion for cardiac injury, ICU monitoring is not warranted such as dobutamine are in order to maintain a due to low risk of developing complications. But in BCI cardiac index > 2.2. All BCI patients with hypo- patients with moderate injury severity, a thorough tension should have an echocardiogram to rule out evaluation is mandatory including cardiac enzymes and pericardial tamponade. an echocardiogram. Telemetry monitoring for 48 h in (4) BCI with wall rupture: BCI patients with rupture of such patients is also recommended [26]. Mattox et al. the chamber wall carry the highest mortality rate. [27] divided patients with BCI into five types that can be Shultz et al. [18] put the incidence of chamber used as a generalized plan to treat these patients. rupture between 0 and 30%. Clinical outcome de- pends on the chamber involved and the integrity of (1) BCI with minor ECG or cardiac enzyme abnor- the pericardium. Mattox et al. [27] reported 85% mality: this is the largest and most benign group of mortality in patients with wall rupture due to BCI. patients presenting with BCI. In a retrospective Majority of these patients expire in the prehospital meta-analysis of 2,210 BCI patients, Maenza et al. setting, but up to 7% survive longer than 30 min [28] found that abnormal EKG or CK-MB corre- [16]. This supports the importance of trauma set- lated with an increased risk of complications tings with rapid transport capabilities. Electric requiring treatment. In another study, Velmahos et changes on EKG, equalization of right- and left- al. prospectively evaluated 333 patients with blunt ventricular pressures on pulmonary artery cather- thoracic trauma with EKG and troponin I at ization, and anatomic abnormalities on echocardi- admission, 4 and 8 h. The authors concluded that ography all help in diagnosing wall rupture. Once the combination of normal EKG and troponin I at the diagnosis is made, emergent pericardiocentesis admission and 8 h later rules out the diagnosis of and/or transport to the OR for a pericardial win- significant BCI (defined as the presence of cardio- dow must be rapidly accomplished. In case there is genic shock, arrhythmias requiring treatment, or cardiac arrest or hemodynamic instability, emer- posttraumatic structural deficits) [23]. Therefore, gent thoracotomy and pericardiotomy is indicated patients presenting with minor EKG or enzyme [30]. Septal ruptures may present with cardiac abnormalities should receive telemetry monitoring failure with left to right shunt. The most common and can also be candidates for echocardiogram, valves involved are the aortic and mitral valves. depending upon their hemodynamic condition. Valvular rupture occurs in up to 6% of BCI pa- (2) BCI with complex arrhythmia: arrhythmias are the tients [31]. Urgent surgical repair is necessary. most common complication associated with BCI. (5) BCI with coronary artery : coronary Atrial arrhythmias are the most common, followed artery lesions represent less than 2% of all BCIs.

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Direct precordial impact, massive injury to the Diagnostic Studies sternum, and resultant myocardial edema are the Plain radiographs of the chest (with identification of all proposed myocardial mechanisms. Symptoms and entry and exit wounds with opaque markers) are the treatment are similar to angina-type chest pain and most common initial imaging studies that are performed myocardial infarction. ST segment elevation war- in patients who present with PLI. In a prospective study rants an emergent echocardiogram and/or angiog- of 4,106 stab wound patients, Ordag et al. reported that raphy. The left anterior descending is more the initial CXR was 92.5% sensitive and had a negative commonly injured than the right coronary artery. predictive value (NPV) of 87% in detecting penetrating chest injuries. The NPV in this study increased to 99.9% at 6 h after injury, and was sufficient enough to permit Outcome outpatient management [39]. CXR has many limita- Only a few studies have evaluated the long-term effects tions, especially in diagnosing small pneumothorax, of BCI. Stuartis et al. [32] concluded that traumatic BCI evolving pulmonary contusions and pulmonary lacera- of the left or right ventricle usually resolves without tions. The literature shows that small pneumothoraces significant functional sequela within 1 year of injury. are not recognized early by admission CXR in 30–50% Lindstaedt et al. [33] in a prospective study of 118 pa- of trauma patients, and are only diagnosed by computed tients with blunt thoracic injury showed that BCI pa- tomography (CT) scan [40]. In another study of 338 chest tients who do not develop acute complications will have trauma patients with paired CT and CXR, 89 had 103 acceptable cardiac function within 1 year of their injury. pneumothoraces, 57 (55%) of which were occult; 6 (11%) were only seen on CT scan [41]. CT scanning is rapidly becoming a primary diagnostic tool, and in some Penetrating Lung Injury centers is being used as the initial test in trauma patients. Background With the advent of the multidetector CT, significant Penetrating chest injuries account for 7–15% of all progress has been made in the speed of data acquisition trauma admissions to major trauma centers [34–36]. In a and image reconstruction. This development has re- study of 755 thoracic trauma patients, Inci et al. [37] sulted in a substantial increase in the number of hemo- demonstrated that hemothorax, dynamically stable patients with PLI that are imaged and pneumothorax (190, 184 and 144, respectively) were with multidetector CT [42]. CT is far more sensitive than the most common injuries. The most frequent symptoms CXR in detecting pulmonary injuries. Wagner et al. are chest pain and dyspnea [38]. Penetrating lung injury showed that the most common injury missed on CXR (PLI) is caused by stabbing or handgun bullets. when compared to CT scan was pulmonary laceration. In this study, 91 patients were found to have a total of 99 Diagnosis lacerations on CT and 5 on CXR; similarly, 143 and 65 The mechanism of PLIs may be categorized according pulmonary contusions, 70 and 5 pneumothoraces, 51 and to the impact velocity into low, medium, or high. All 19 hemothorax, and 2 and 1 pneumopericardium were stab wounds are considered low-velocity injuries. High- detected on CT and CXR, respectively [43]. Following a velocity injuries include bullet wounds caused by rifles pulmonary injury, the pericardium and the pleural and heavy military weapons. Medium velocity injuries spaces can be assessed by using a bedside sonogram, but are usually caused by handguns. The clinical conse- its efficacy in excluding major thoracic injuries fails to quences depend on the mechanism of the injury, the compete with that of a CT. In a study of 382 location of the injury, associated injuries, and under- patients, Dulchavsky et al. [44] showed that pneumo- lying illnesses. thorax was demonstrated on CXR in 39 patients and confirmed by ultrasound in 37 of the 39 patients (95% Initial Evaluation sensitivity); two pneumothoraces could not be diag- The goal of initial evaluation of patients with thoracic nosed because of subcutaneous air and the true-negative trauma is to identify those with significant injuries. Life- rate was 100%. Serial CT of the chest is increasingly used threatening conditions (such as airway compromise, to evaluate transmediastinal gunshot wounds and direct, impaired respiratory mechanics, and/or hemorrhagic if needed, further organ-specific tests, such as esopha- shock) must be rapidly identified and stabilized (pri- gography, aortography, or bronchoscopy. Video-as- mary survey). The full extent of the injuries can then be sisted thoracic surgery (VATS) is also a safe and determined with a detailed history, careful physical effective way to diagnose and manage stable patients examination, and diagnostic testing (secondary survey). with penetrating chest injuries. In a study by Potaris et al.

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23 hemodynamically stable patients underwent VATS by inserting a 12- or 14-gauge angiocatheter into the for indications such as posttraumatic hemothorax, con- second intercostal space in the midclavicular line of the tinued hemorrhage and persistent pneumothorax. There affected hemithorax. Pain management and pulmonary was no mortality and complications occurred in three toileting should also be initiated at this point [42, 47]. In patients (13%). Potaris et al. [45] concluded that VATS general, patients who are symptomatic or show > 20% provides diagnostic accuracy and therapeutic efficacy in pneumothorax are considered for chest tube placement hemodynamically stable patients with thoracic injuries. [42]. Prophylactic chest tube placement is considered in patients with occult pneumothoraces, who will be placed Management on a mechanical ventilator or undergoing lengthy sur- Initial Management Decisions gical procedures. The general management for patients with penetrating chest injuries who are symptomatic (chest pain or Hemothorax abnormal physical examination), with multiple injuries, The main causes of hemothorax are laceration of the or high-velocity penetrating mechanisms include pro- lung, intercostal artery, and internal mammary artery. viding supplemental oxygen, monitoring vital signs Due to the low-pressure vascular system and rich including pulse oximetry and prompt surgical consulta- concentration of tissue thromboplastin in the , tion. In case of severe respiratory distress, hemodynamic any bleeding is usually self-controlled and the vast instability and Glasgow coma scale (GCS) score < 9, majority can safely be managed by simple thoracos- advanced airway management, including endotracheal tomy tube drainage. Although tube thoracostomy is a intubation, should be considered. Judicious fluids should straightforward and lifesaving procedure, it should not be provided as needed to support blood pressure and be taken too lightly. A review of almost 600 tube improve end-organ perfusion. Although patients with thoracostomies by Demetriades et al. [35] revealed a pulmonary contusions may develop pulmonary edema complication rate of 21%. with excessive fluid administration, this is rarely a con- sideration during initial management and never takes Thoracotomy and its Indications precedence over supporting circulation. In the presence of severe bleeding, a thoracotomy is necessary. The indications are listed below: Surgical Management The majority of PLIs are managed by simple chest tube • Greater than 1,500 ml of blood is evacuated imme- placement. PLIs rarely need operative repair. In a diately after initial chest tube insertion. retrospective review of 1,168 patients (382 gunshot • Bleeding from the chest continues, defined as wound, 784 stab wounds) with PLI, Robison et al. > 200 ml/h for 4–6 consecutive hours. showed that the majority (74% gunshot wound, 77% • Hemodynamic instability; systolic blood pressure < stab wounds) of PLIs were treated with simple chest 80 mmHg despite aggressive blood/volume resusci- tubes alone. Sixty-eight patients (6%) required oper- tation. ative repair of pulmonary hilar or parenchymal injury. • > 150 ml/h for 3 h for the elderly. Of the 18 patients that required pulmonary resection, 9 required wedge or segmental resection, 6 required It is important to realize that chest tube output may be lobectomy and 3 pneumonectomy [46]. misleading. A hemodynamically unstable patient should be operated even if the output does not meet the above Pneumothorax guidelines. On the other hand a patient who, despite A small pneumothorax (< 1–2 cm) can be observed with significant output, remains very stable could benefit follow-up CXR, taken within 6–8 h. By monitoring the from a longer trial of nonoperative management. respiratory status, small pneumothoraces usually do not VATS has been suggested as an alternative to require further treatment. Larger pneumothoraces re- thoracotomy in the management of hemodynamically quire the insertion of chest tube with an underwater seal. stable patients but has not been widely used. In a ret- Treatment of an open pneumothorax is geared at rospective review of 77 patients, Ben-Nun et al. com- returning normal ventilation by establishing an ade- pared 37 patients in the VATS group to 40 patients in quate airway, and closing the wound by placing an the thoracotomy group. No deaths occurred in either occlusive dressing on three sides. Tension pneumotho- group. The incidence of wound and pulmonary com- rax is a life-threatening situation that requires immedi- plication were higher in the thoracotomy group. The ate decompression of the chest to release the trapped air author concluded that in hemodynamically stable pa-

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tients VATS is better tolerated, has fewer long-term (8 patients). The GSW group of patients had a longer complications and has more cosmetic satisfaction as hospital stay (11.7 and 7.25 days), longer time with tube compared to thoracotomy [48]. thoracostomy (5.98 and 4.18 days), more injured abdom- inal organs (3.8 and 2.4 organs) and higher mortality (7 Pulmonary Parenchymal Injuries and 4%) than the stab wound group. The overall mortality Pulmonary parenchymal injuries include pulmonary was 5% [54]. In the study conducted by Robison et al. [46] contusions and pulmonary lacerations. Most pulmonary mortality for all thoracic injuries was 2.3%; for those contusions are managed nonoperatively, as described treated with chest tube alone, 0.7%; for pulmonary hilar later in this chapter. Pulmonary lacerations result in injuries, 30%; for pulmonary parenchymal injuries, 8.6%; bleeding and air leaks. The lacerations may extend and for injuries necessitating lung resection was 28%. from the surface of the lung towards the hilum or the trajectory of the penetrating object [49]. They can vary from minor lacerations to lobar bisection. Both types of Blunt Pulmonary Injury pulmonary parenchymal injuries can result in massive Background lethal bleeding requiring emergency thoracotomies. A Chest trauma ranks third behind head and extremity range of 9–15% of patients sustaining a thoracic injury trauma in major accidents in the United States. About require a thoracotomy, and 3–31% of all patients who 20–25% of all trauma deaths, and  16,000 deaths per require thoracotomy require lung resection [50, 51]. year, are related to thoracic injuries in the United States [55]. Blunt thoracic injuries are seen more Lung-Sparing Techniques commonly than penetrating chest trauma, with the Main methods used to control bleeding include anatom- most frequent causes being motor vehicle accidents ical and non-anatmical lung resections and suturing (MVA), falls and crush injuries [56]. Stewart et al. [57] superficial lacerations. In a study of 40 patients who showed that blunt injuries to the chest lead to higher underwent thoracic surgery for PLI, Velmahos et al. [52] mortality than penetrating injuries (33 vs. 0%) because included 5 (12.5%) with anatomical lobectomy, 3 (7.5%) they are extensive and associated with a higher inci- with pneumonorrhaphy, 9 (22.5%) with stapled wedge dence of multiple system damage. resection, and 23 (57.5%) with stapled tractotomy; the- mortality rate was 5%. Lung-sparing techniques such as Pulmonary Contusion tractotomy, wedge resection and pneumonorrhaphy, have Pulmonary contusions are the most common lung injuries shown to reduce mortality. A lobectomy, however, may in blunt chest trauma, occurring in 17–75% of patients be necessary with extensive parenchymal damage or hilar [58]. Wagner et al. described that the formation of pul- injuries. In this situation, en-masse stapled pneumonec- monary contusions was due to pulmonary laceration with tomy is preferred over an anatomical lobectomy. In situ- resultant hemorrhage into the alveolar spaces, and clas- ations with significant bleeding or major air leak from a sified four types of lacerations that are associated with missile or knife tract, a tractotomy is the preferred tech- pulmonary contusions as a result of the following: chest nique. Suturing of the entry or exit of the tract is ill-advised wall compression against the lung parenchyma at the time because it creates a milieu for air embolism [35]. Huh et al. of impact (Type I), by shearing of lung parenchyma across demonstrated lung-sparing techniques in 397 patients; bony structures (Type II), by rib fractures (Type III), or operative interventions included pneumonorraphy by sudden chest wall compression that displaces the lung (58%), wedge resection or lobectomy (21%), tractotomy inwardly next to thick pleuropulmonary adhesions (Type (11%), pneumonectomy (8%), and evacuation of hema- IV) [43]. Type I is the most common and is seen in young toma (2%). Overall the mortality rate was 27% and was patients (age < 40 years), whereas, Type III is next most greatest for pneumonectomy reaching 70% [53]. common and is seen in the older population.

Outcome Diagnosis No resuscitative measures should be attempted in most History of blunt trauma to the chest, motor vehicle patients with no vital signs at the scene of injury or with crashes, falls from a height, and blast injuries should obviously nonsurvivable injuries (e.g., massive cardiac point toward the possibility of a pulmonary contusion. destruction). Gunshot wounds are more destructive than Physical examination may be unrevealing; however, in stab wounds. Vasquez et al. compared GSW with stab the presence of a severe contusion, breathing may be wounds and demonstrated that the most frequent com- compromised. Pulmonary contusions are seen on the plications were respiratory (34 patients) and neurological CXR and CT scan as ill-defined, single or multiple,

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patchy, ground-glass regions of opacification [57]. CT Pulmonary Lacerations and scans have shown to be clearly more sensitive in dem- Pulmonary parenchymal lacerations are a hallmark of onstrating changes seen with pulmonary contusions as penetrating chest injury, but are also seen after severe blunt compared to CXR [58]. Schild et al. compared CXR and trauma. Although blood vessels and bronchial airways are chest CT scans in a dog model of pulmonary contusion. disrupted, pneumothorax is the main presentation, and Initial CXR films failed to visualize the lung lesion in bleeding is of minor consequence. If the laceration involves 62% of the subjects, whereas 100% of the lesions were thevisceralpleuraandthecommunication with the pleural discernible by CT scan. At 6 h, contusions were still not space remains patent, then hemothorax, pneumothorax, visible in 21% of CXR. The extent of lesions was also or hemopneumothorax results. If the visceral pleura is underestimated much more frequently by CXR than by torn but seals quickly, blood, air, or both can accumulate CT scan (58 vs. 8%) [59]. CXR reveals consolidation and within the lung and result in the development of a hema- pulmonary infiltration at the site of injury, but these toma, cyst, or a cyst containing blood. findings may lag 12–24 h. Blair et al. [60] showed that Pulmonary hematomas are formed when pulmonary radiographs may have a delay of up to 6 h, before pul- lacerations are filled with blood. The incidence of monary contusions become visible on film. Pulmonary hematomas developing in pulmonary contusions is from contusions are cleared within 2–14 on CXR days 4 to 11% [43]. Pulmonary hematomas generally do not according to severity [61]. Persistence of contusions interfere with gas exchange, nor do they produce sig- beyond this time period indicates the development of nificant intrapulmonary shunting, but they are a major complications such as pneumonia, aspiration or adult risk factor for and lung abscess formation. respiratory distress syndrome (ARDS) [62]. Diagnosis Management CT is superior to radiography in detecting lacerations as Pulmonary contusions are managed conservatively. well as hematomas [43, 58]. Shanmuganathan et al. The management of patients with pulmonary contu- showed that on CXR, pulmonary lacerations remain ob- sions is based on three factors: overall stability of the scured for 48–72 h until the surrounding contusions starts patient, adequacy of oxygenation, and pulmonary to resolve. The authors also demonstrated that lacerations mechanics. are ovoid-to-round in shape because of the elastic recoil of Initial treatment of pulmonary contusion includes thelungtissue,andhaveathick2-to3-mmpseudo- administering oxygen to maintain arterial oxygen satu- membrane of adjacent compressed lung parenchyma [63]. ration greater than 90%, intensive care unit monitoring Unlike pulmonary contusions, lacerations may take of oxygen saturation, aggressive pulmonary toilet to weeks to months to resolve. Wagner et al. [43] demon- help clear body secretions from the airway, and admin- strated that on CT scans, hematomas shrink less than istration of analgesics. If ventilation is inadequate, 0.5 cm in 3 weeks, whereas on conventional radiographs, intubation and mechanical ventilation are indicated. they are reported to resolve within 2–4 weeks of injury. While on ventilator support, the ideal inspired oxygen In the absence of previous radiographs or serial CT scans, should not exceed 50% while maintaining a PaO2 of if the lesion does not resolve within 4 weeks the possi- more than 60 mmHg. If the level of oxygen cannot be bility of a neoplasm must be considered, and fine-needle maintained, positive end-expiratory pressure or contin- aspiration of the nodule or surgical resection should be uous positive airway pressure is added. Fluid manage- sought to establish the nature of the lesion [64]. ment remains controversial. Fine tuning fluid administration to be consistent with the metabolic deficit Management without flooding the lungs may be assisted by attentive Although most pulmonary lacerations are successfully hemodynamic and tissue perfusion monitoring. Pro- treated with tube thoracostomy or with a thoracoscopic phylactic antibiotics and steroids are not indicated. or surgical procedure, about 5% of patients require surgical intervention for either persistent bleeding or Outcome unresolved air leak. Peripheral lacerations seen during In one series, 11% of patients with severe isolated pul- operation can be oversewn (pneumonorrhaphy), sta- monary contusions died, whereas the mortality rate was pled, or wedged out. Central lacerations may disrupt much higher (22%) in patients with associated injuries. major vessels and bronchi, resulting in massive bleed- ARDS developed in 17% of patients with isolated pul- ing, large air leaks, and, although rarely seen, bron- monary contusions and in 78% of patients with two or chopulmonary venous fistulas resulting in systemic air more simultaneous associated injuries in other series. embolization; all these require immediate operation.

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