Chp16ThoracicInjuries.pdf

Thoracic Injuries

Chapter 16

Thoracic Injuries

Introduction

About 15% of war injuries involve the chest. Of those, 10% are

superficial (soft tissue only) requiring only basic wound

treatment. The remaining 90% of chest injuries are almost all

penetrating.

Those injuries involving the central column of the chest (heart,

great vessels, pulmonary hilum) are generally fatal on the

battlefield. Injuries of the lung parenchyma (the vast majority)

can be managed by the insertion of a chest tube and basic wound

treatment. Although penetrating injuries are most common,

blunt chest trauma may occur and can result in disruption of the

contents of the thorax as well as injury to the chest wall itself.

Blast injuries can result in the rupture of air-filled structures

(the lung) as well as penetrating injuries from fragments.

The immediate recognition and treatment of tension

pneumothorax is the single most important and life-

saving intervention in the treatment of chest injuries in

combat. Distended neck veins, tracheal shift, decreased

breath sounds, and hyperresonance in the affected

hemithorax, and hypotension are the cardinal signs.

None or all may be present. Immediate decompression

is lifesaving.

With the advent of body armor, it is hoped that the majority of

thoracic injuries seen in past conflicts will be avoided.

Unfortunately, there will be individuals who will not have such

protection, as well as others who will sustain chest injuries

despite protection.

16.1

Emergency War Surgery

Superior border is at the level of the clavicles anteriorly and

the junction of the C7-T1 vertebral bodies posteriorly. The

thoracic inlet at that level contains major arteries (common

carotids, vertebrals), veins (anterior and internal jugulars),

trachea, esophagus, and spinal cord.

Within or traversing the container of the chest itself are found

the heart and coronary vessels, great vessels including arteries

(aorta, arch, inominate, right subclavian, common carotid,

left subclavian, and descending aorta), veins (superior and

inferior vena cava, azygous vein, brachiocephalic vein),

pulmonary arteries and veins, distal trachea and main stem

bronchi, lungs, and esophagus.

The inferior border is described by the diaphragm, attached

anteriorly at the T6 level and gradually sloping posteriorly

to the T12 level.

Penetrating thoracic injuries below the T4 level (nipple

line) have a high probability of involving abdominal

structures (Fig. 16-1).

Evaluation and Diagnosis

Knowledge of the mechanism of

injury (eg, blast, fragment, among

others) may increase the index of

suspicion for a particular injury. A

complete and accurate diagnosis is

usually not possible because of the

limited diagnostic tools available in

the setting of combat trauma. None-

theless, because injuries to the chest

can profoundly affect breathing and

circulation (and on rare occasion, the

airway), a complete and rapid assess-

ment of each injury is mandatory.

Fig. 16-1. Thoracic incision

of abdominal contents.

If the casualty is able to talk, there is reasonable assurance

that the airway is intact.

16.2

Anatomic Considerations

Thoracic Injuries

Life-Threatening Injuries

Injuries not immediately obvious, yet requiring urgent

attention, include tension pneumothorax, massive

hemothorax, and cardiac tamponade.

Tension Pneumothorax.

ο A patient with a known chest injury presenting with an

open airway and difficulty breathing has a tension

pneumothorax until proven otherwise and requires rapid

decompression and the insertion of a chest tube.

Massive Hemothorax.

ο The return of blood may indicate a significant intrathoracic

injury. Generally, the immediate return of 1,500 cc of blood

mandates thoracotomy (especially if the wound was

sustained within the past hour). With less blood initially,

but a continued loss of 200 cc/hour for over 4 hours ,

thoracotomy is indicated.

ο Casualties with massive thoracic hemorrhage require

damage control techniques (see Chapter 12, Damage

Control Surgery).

Cardiac Tamponade.

ο Distended neck veins (may be absent with significant

blood loss) in the presence of clear breath sounds and

hypotension indicate the possibility of life-threatening

cardiac tamponade.

ο Fluid resuscitation may temporarily stabilize a patient in

tamponade.

ο Perform an ultrasound (US) with a stable patient.

♦ If positive, proceed to the OR (pericardial window,

sternotomy, thoracotomy). Any pericardial blood

mandates median sternotomy/thoracotomy.

♦ A negative US requires either repeat US or pericardial

window, depending on level of clinical suspicion.

ο Pericardiocentesis is only a stopgap measure on the way

to definitive surgical repair.

16.3

Emergency War Surgery

Open pneumothorax (hole in chest wall) is treated by placing

a chest tube and sealing the hole. Alternatives include one-

way valve chest dressings or a square piece of plastic dressing

taped to the chest on three sides.

Flail chest (entire segment of the chest wall floating due to

fractures of a block of ribs, with two fractures on each rib)

will require treatment (either airway intubation or obser-

vation) based on the severity of the underlying lung injury.

In cases where intubation is not required, repeated intercostal

nerve blocks with a long-acting local anesthetic such as

Marcaine may be very helpful in relieving pain and limiting

atelectasis and other pulmonary complications.

Surgical Management

Most penetrating chest injuries reaching medical

attention are adequately treated with tube thoracostomy

(chest tube) alone.

Indications.

ο Known or suspected tension pneumothorax.

ο Pneumothorax (including open).

ο Hemothorax.

ο Any penetrating chest injury requiring transport (manda-

tory in case of aeromedical evacuation).

Procedure (Fig. 16-2).

ο In cases of tension pneumothorax, immediate decom-

pression with a large bore needle is lifesaving . An IV

catheter (14/16/18 gauge at least 2–3 inches in length) is

inserted in the midclavicular line in the second interspace

(approximately 2 fingerbreadths below the clavicle on the

adult male). Entry is confirmed by the sound of air passing

through the catheter. This must be rapidly followed by

the insertion of a chest tube.

ο In a contaminated environment, a single gram of IV

cefazolin (Ancef) is recommended.

ο If time allows, prep the anterior and lateral chest on the

affected side with povidone-iodine.

16.4

Tube thoracostomy (chest tube).

Thoracic Injuries

ο Identify the incision site along the anterior axillary line,

intersecting the 5 th or 6 th rib.

ο Inject a local anesthetic in the awake patient, if conditions

allow.

ο Make a transverse incision, 3–4 cm in length, along and

centered over the rib, carrying it down to the bone.

6th Rib Site

4 5 6 7 8

1 2

9 10

Axillary Line

Lungs

1 2 3 4 5 6 7 8

9 110

Heimlich valve

Suction/ Open

Chest tube

Fig. 16-2. Procedure for tube thoracostomy.

16.5

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