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ADVANCES IN THE DIAGNOSIS AND TREATMENT OF THORACIC TRAUMA
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ADVANCES IN THE DIAGNOSIS AND TREATMENT OF THORACIC TRAUMA David V. Feliciano, MD, and Grace S. Rozycki, MD, RDMS
ADVANCES IN THE DIAGNOSIS OF THORACIC TRAUMA Value of Admission Electrocardiogram in the Diagnosis of Blunt Cardiac Injury
Although much has been written about the clinical entity of blunt cardiac injury, there are few patients that require treatmer1t.5~Usually caused by a direct precordial blow sustained in a motor vehicle crash 80% to 90% of the time, the term blunt cardiac injury now includes an entire spectrum of injuries. Most publications describe new-onset sinus tachycardia as the most common finding on an admission electrocardiogram (ECG), but the precise pathophysiology has never been elucidated. Other reported new-onset arrhythmias include atrial fibrillation or flutter, premature ventricular contractions, and ventricular tachycardia or fibrillati~n.~~ New-onset conduction disturbances also are noted on the admission ECGs of some patients with true myocardial contusion. In addition to T-wave and STsegment abnormalities, which would be expected with a bruise to the ventricular myocardium, Tenzer's review listed first-degree heart block, right bundle-branch block, right bundle-branch block with hemiblock, and third-degree heart block as having occurred Tachyarrhythmias or conduction disturbances are the most common clinical manifestations of cardiac contusion, and the admission ECG is the most logical diagnostic tool of choice. Disparaged by the authors of studies on radioisotope and transesophageal echocardiscanning,67,68 transthoracic ech~cardiography,~~ ographyS5recent reports have repeatedly documented that the initial ECG is an
From the Department of Surgery, Emory University School of Medicine (DVF, GSR); and Department of Surgery (DVF) and Division of Trauma/Surgical Critical Care (GSR), Grady Memorial Hospital, Atlanta, Georgia
SURGICAL CLINICS OF NORTH AMERICA VOLUME 79 * NUMBER 6 * DECEMBER 1999
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excellent filter when evaluating patients with blunt thoracic trauma.8,29, 39 In the normotensive patient with absence of new-onset tachyarrhythmias or conduction disturbances on the initial ECG and during a period of in-emergency center observation, blunt cardiac injury of clinical significance is not When new-onset tachyarrhythmias or conduction disturbances, unexplained hypotension, or a history of cardiac disease are present in the victim of blunt thoracic trauma, admission and monitoring are justified. Because numerous studies have demonstrated the imprecise relationship between creatine phosphokinase myocardial band (CPK-MB), cardiac troponin T (cT,T), and cardiac troponin I (cT,I) levels, they should not be drawn in the admitted patient unless there is a question of a concomitant myocardial infarction.', 6, 27, 39, 45 Transthoracic or transesophageal echocardiography is used as an adjunct in patients with persistent ECG abnormalities or unexplained hypotension after blunt thoracic trauma.I2,73
Value of Surgeon-Performed Ultrasound in the Diagnosis of Cardiac Rupture or Perforation and Traumatic Hemothorax
At the far end of the spectrum of blunt cardiac injury are rupture at the caval-atrial junction, left atrial appendage, or right ventricular outflow 88 Similarly, one of the most lethal penetrating thoracic wounds is that involving the heart with secondary tamponade or exsanguination. By definition, patients with the larger ruptures or perforations will be dead at the scene of injury or will die in transit (approximately 60% to 80% of all patients with penetrating cardiac wounds in an urban e n ~ i r o n m e n t ) . ~ ~ In the remaining small subset of patients, early diagnosis and operative repair lead to a survival rate of 70% to 80% in experienced trauma centers.13,l9 Although much has been written about diagnostic pericardiocentesis in the emergency center in such patient^,'^, 77 the treatment of choice in patients who are hypotensive or in extremis is emergency thoracotomy with cardiorrhaphy. In patients who are normotensive or mildly hypotensive, diagnostic choices in the 1970s and 1980s included measurement of central venous pressure,74subxyphoid pericardial win do^,^ or transthoracic echocardiography by a cardiologist.86 Over the past 10 years, numerous reports have documented that echocardiography performed in the emergency center by surgeons or specialists in emergency medicine using a 3.5 MHz (1 MHz = lo6 cycles/ sec) general access transducer is In the study by Rozycki et al,71 246 the diagnostic test of choice (Fig. l).69-71 patients with penetrating thoracic wounds were evaluated by surgeon-performed ultrasound. There were 236 true-negative results and 10 true-positive results. In the latter group, the mean time (available in eight patients) from ultrasound to operation was 12.1 minutes; all survived after repair of their cardiac wounds. A follow-up study by Rozycki et aF9 in 313 patients with penetrating precordial or transthoracic wounds resulted in 289 true-negative examinations, two false-positive examinations, and 22 true-positive examinations. In the latter group, all patients survived when surgery was immediately performed by the surgeon-sonographer. Finally, Rozycki et a170 completed a multicenter study in which emergency pericardial sonograms were performed by ultrasound technicians, cardiologists, or surgeons. In a series of 261 patients with penetrating precordial or transthoracic wounds evaluated at five Level I trauma centers, 29 (11.1%)had true-positive studies and 28 survived after emergency cardiac repair. The accuracy (97.3%), specificity (96.9%), and sensitivity
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Figure 1. Cardiac tamponade detected on surgeon-performed ultrasound using a 3.5-MHZ transducer.
(100%) were equivalent to those reported in the previous study from Grady Memorial Hospital / Emory University.69 Surgeon-performed ultrasound also has been found to be useful in the detection of a post-traumatic hemothorax (Fig. 2). In the prospective study by Sisley et d75surgeon-performed ultrasound detected a hemothorax subsequently
Figure 2. Post-traumatic hemothorax detected on surgeon-performed ultrasound using a 3.5-MHz transducer.
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confirmed by output from a thoracostomy tube in 39 of 40 patients. The 97.5% sensitivity and 99.7% specificity of ultrasound were equivalent to the 92.5% sensitivity and 99.7% specificity of portable chest radiographs, whereas the ultrasound examination was significantly faster. Value of Standard CT in Diagnosis
Although there has been increasing use of standard thoracic CT as an adjunct to the routine chest radiograph in the evaluation of patients with blunt or penetrating thoracic trauma over the past 10 years, its value is 5*, 65, 79 Lesions more commonly identified on standard thoracic CT versus those diagnosed on routine chest radiographs have included hemothorax, pneumothorax, pulmonary contusions, atelectasis, and diaphragmatic injuries.49,52, 79 The detection of a subclinical presentation of any of these entities with the exception of the traumatic diaphragmatic hernia may not have a significant effect on management and, therefore, the cost of the study is a concern (see article by Mirvis elsewhere in this issue). Diagnostic Modalities Used in the Detection of Traumatic Rupture of the Thoracic Aorta
Using eight radiographic signs of mediastinal abnormality on a chest radiograph (i.e., abnormal aortic contour or size, opacification of the aortopulmonary window, depression of left mainstem bronchus, tracheal shift to the right, deviation of the nasogastric tube to the right, widening of the right paratracheal stripe, presence of an apical pleural cap, widening of the paraspinal line), Woodring and Kings9 detected abnormalities in 30 of 32 patients (94%) with subsequently proven injuries to the thoracic aorta or brachiocephalic vessels. A strongly suggestive history (i.e., motor vehicle, motorcycle, or auto-pedestrian crash greater than 40 to 45 mph, significant deceleration in a motor vehicle crash, severe broadside collision, death of another victim in the crash, presence of a shoulder harness restraint) or abnormal upright chest radiograph or one performed in the reverse Trendelenburg position for the supine patient, therefore, detects the subset of patients that needs further diagnostic screening (Fig. 3). There is now a significant amount of data on the use of transesophageal echocardiography (TEE) in detecting blunt rupture of the thoracic aorta or a brachiocephalic vessel.l0,14, 16, 46, 56, sl, In the report by Buckmaster et al,14 of 121 of 160 patients with possible blunt injury to the thoracic aorta, two-dimensional TEE with color flow Doppler examinations were equivocal in 3, positive in 14 (all confirmed), and true-negative in the remainder. In contrast, there were 1 false-positive and 4 false-negative aortograms in 148 of 160 patients in the same series. In the recent prospective study by Chirillo et a1,l6 TEE had a 93% sensitivity, 98% specificity, and 98% accuracy in detecting blunt rupture of the thoracic aorta. There are, however, obvious limitations to the use of TEE in evaluating acutely injured patients, including the following: 1. Need to consult the cardiology or anesthesiology departments to perform the study 2. Operator-dependent 3. Contraindication to esophageal intubation
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ADVANCES IN THE DIAGNOSIS AND TREATMENT OF THORACIC TRAUMA
Figure 3. Rapidly expanding rupture of the descending thoracic aorta at the isthmus. Patient died shortly after transfer to the trauma center.
4. Equivocal findings 5. Less than ideal visualization of the ascending aorta behind the right mainstem bronchus, branches of the transverse arch, and the descending thoracic aorta when a pneumothorax is present'O, s2
Also, some preliminary studies in major trauma centers have shown a poor sensitivity in detecting blunt rupture of the descending thoracic aorta.53Recognizing these limitations, TEE with a biplanar or multiplanar probe still is being evaluated for its overall accuracy as compared with chest radiographs, helical CT, or conventional aortography. Spiral or helical CT has been used for less than 10 years in this This technique allows for an entire anatomic region to be scanned rapidly after intravenous injection of contrast. Several studies, summarized in Table 1, have assessed the usefulness of this technique in detecting blunt rupture of the thoracic aorta.=, 32, 54 The guidelines suggested for current use of spiral CT for patients with blunt thoracic trauma in the article by Mirvis et a154are listed as follows: 1. Abnormal chest radiograph is followed by contrast-enhanced spiral thoracic CT
Table 1. USE OF SPIRAL CT IN THE DIAGNOSIS OF BLUNT AORTIC RUPTURE Spiral CT (%)
Aortography (%)
Sensitivity Specificity Accuracy Sensitivity Specificity Accuracy
Gavant et a132 Fabian et a123 Mirvis et a P
100 100 100
81.7 83 99.7
-
86
99.7
99.4 92
-
96.3 99
-
-
-
97
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2. Absence of mediastinal hemorrhage or direct signs of aortic injury by high quality CT excludes the diagnosis of injury to the thoracic aorta 3. Direct evidence of injury to the thoracic aorta or other great vessel should be followed by aortography or thoracotomy based on the experience of the institution 4. Spiral CT evidence of hemorrhage in the anterior mediastinum or paravertebral area in the absence of signs of injury to the thoracic aorta rules out injury to this structure 5. Evidence of mediastinal hemorrhage in the area of the thoracic aorta or great vessels without direct signs of vascular injury mandates aortograPhY Standard aortography or intra-arterial digital subtraction aortography (DSA) performed through a retrograde transfemoral or transaxillary approach continues to be the standard of care that other diagnostic techniques are measured against. Most centers now use DSA, a study that can be performed in 15 to 30 minutes and that has an accuracy of 97% to 100%.22, 23* 55 The major advantage to use of these techniques, in addition to accuracy, is the ability to detect injuries in all areas of the thoracic aorta and its branches.2 The disadvantage continues to be the inevitable delay as the interventional angiography team must be contacted and return to the hospital to complete this brief study. There is a slowly emerging trend to use spiral CT as an intermediate step before thoracic DSA or even as a replacement for DSA, and it is likely that the use of DSA or conventional aortography will decrease significantly in the future. Thoracoscopy
The use of video-assisted thoracoscopy continues to increase in major trauma centers. The indications for thoracoscopy in trauma include early evacuation of a clotted hem0thorax,3~evaluation of the left hemidiaphragm after pene6o and repair of pulmonary lacerations trating left thoracoabdominal 43 In patients with a retained hemoor assistance with pulmonary l~bectomy.~~, thorax, spiking temperature, and leukocytosis, thoracoscopy under one-lung anesthesia is an ideal technique for inspection of thoracic contents and evacuation of clotted blood that might eventually lead to empyema. With penetrating wounds to the left thoracoabdomen, a small injury to the left hemidiaphragm is not detectable on physical examination and may not be visualized on an early chest radiograph. Because the consequences of missing such an injury may be severe,26thoracoscopy may be used to rule one out when the track of the missile or stab wound is suggestive. The accuracy of the video-assisted technique is excellent,6oand the high incidence of such injuries with penetrating wounds to the left thoracoabdomen (59% for gunshot wounds, 32% for stab wounds in one recent study) justifies its continued ~ s a g e . With 5 ~ the large experience with videoassisted thoracoscopic techniques in treating nontrauma pulmonary lesions, it is not surprising that such techniques also have been used to treat pulmonary laceration^.^^, 43
ADVANCES IN THE TREATMENT OF THORACIC TRAUMA Current Role of Emergency Center Thoracotomy
Following the publication of the paper by Blalock and Ravitch in 19439 advocating nonoperative treatment for cardiac tamponade, there was presum-
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ably some decrease in the number of emergency thoracotomies in urban trauma centers. The rapid proliferation of penetrating thoracic wounds in such centers over the next 10 years quickly led to a more aggressive approach using emergency center thoracotomy.' The current strong indications for emergency center thoracotomy are listed as follows25: 1. Penetrating thoracic wound with agonal state or recent cardiac arrest on arrival, deterioration or cardiac arrest after care has been started in the emergency center, or uncontrolled hemorrhage from the thoracic inlet or out of a thoracostomy tube 2. Suspected subclavian vessel injury with intrapleural exsanguination 3. Need for open cardiac massage or occlusion of the descending thoracic aorta before laparotomy in the operating room 4. Need for open cardiac massage or occlusion of the descending thoracic aorta when countershock or closed chest cardiac massage is ineffective (i.e., cardiopulmonary arrest) Relative indications would include a recent cardiac arrest and associated flail chest, multiple blunt trauma, pregnancy or an abnormality of the chest wall, or the need for fluid infusion by an intracardiac route. Strong contraindications to use of the technique include penetrating trauma with no signs of life in the field and blunt trauma with no signs of life on arrival in the emergency center.I7 The technique continues to use a left anterolateral thoracotomy at the lower edge of the male nipple when a penetrating left thoracic wound is present. When a penetrating right thoracic wound is present and the patient is agonal on arrival, a bilateral anterolateral thoracotomy is performed. If intrapleural exsanguination from a suspected injury to a subclavian vessel is believed to be present, an anterolateral thoracotomy at a higher intercostal space is appropriate. Cross-clamping of the descending thoracic aorta is, however, more difficult should the higher incision be made on the left side. This latter maneuver is performed by first lifting the posterolateral edge of the left lung out of the hemithorax. Once the mediastinal pleura over the descending thoracic aorta and vertebral bodies is visualized, it is opened with a long DeBakey aortic clamp. The descending thoracic aorta then is encircled with the surgeon's left index finger before the cross-clamp is applied. Subsequent maneuvers for cardiac massage or repair include longitudinal pericardiotomy above the left phrenic nerve, exposure of the cardiac wound or rupture, and use of fingers, staples, sutures, or balloons for control of hemorrhage. Because of the cost and low yield of emergency center thoracotomy, the technique recently has been used more selectively. The overall survival of approximately 10% is somewhat deceptive, however, because the survival in the subset of patients with penetrating cardiac wounds is significantly better. In the article by Ivatury et a1,4I 22 patients with penetrating cardiac injuries arrived in the emergency center without "detectable vital signs, cardiac activity, or spontaneous respirations." Cardiac function was restored in 16 patients (72.7%),and 8 patients (36.4%) survived without neurologic sequelae. Currently, the highest survival after emergency center thoracotomy will be in patients with tamponade from an anterior penetrating stab wound to the heart only, a short prehospital time, and some vital signs present on admission. Staple Closure of Cardiac Wounds
Repair of penetrating cardiac wounds with a standard skin stapler with 6mm staples in the emergency center or operating room was first reported by
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Macho et a148in 1993. In their retrospective review of 28 patients (with 33 cardiac wounds), control of hemorrhage with staples was achieved in 26 patients (93%). This control of hemorrhage took less than 1 minute in 20 patients and less than 2 minutes in 6 patients. The authors noted that the technique was rapidly performed, “hghly effective” in controlling hemorrhage, and avoided the risk of suturing the beating heart in a population with a known increased incidence of blood-borne viruses. The successful use of staples has been duplicated in other centers and also has been studied in a swine model. In the study by Mayrose et al?O 2-cm full-thickness ventricular wounds in swine were repaired with sutures or staples. After sacrifice of the animals and removal of 4-cm strips of myocardium oriented perpendicular to the cardiac repair, acute tensile strength was found to be similar in the sutured and stapled repairs. The availability of wide skin staplers is recommended for all emergency centers where penetrating cardiac wounds might be treated. Pulmonotomy for the Control of Bleeding from the Lung
Over the past decade, a frequently used techmque in urban trauma centers has been direct entrance into the lung to perform selective ligation of bleeding vessels5, 84 Known as pulmonotomy or pulmonary tractotomy, the technique developed for the same reasons that more selective operative approaches became popular in the management of hepatic trauma. The oversewing of the bleeding entrance and exit sites in injured lobes was effective in tamponading most injuries that required thoracotomy in the past. A small subset of patients, however, continued to bleed and eventually developed asphyxiation secondary to continuing hemorrhage back into the tracheobronchial tree. Another small subset of patients continued to bleed through the sutured entrance and exit sites and died from intrapleural hemorrhage. Pulmonotomy is performed by first placing long vascular clamps into a lobar entrance or exit site or through both simultaneously, if possible. The pulmonary parenchyma then is divided between the clamps, which are used as retractors. Selective ligation of injured vessels in the pulmonary parenchyma is performed with suture material of the surgeon’s choice. An alternative approach is to use a linear staplers0to connect the entrance and exit sites and complete the pulmonotomy. After control of hemorrhage has been achieved, the site of the pulmonotomy is reapproximated with an 0 or 2-0 continuous absorbable suture. A related approach has been the use of en bloc stapling of the pulmonary hilum when trauma pneumonectomy has been performed. In the review by Wagner et a1,s3nine patients underwent trauma pneumonectomy with a 55- or 90-mm stapler used to close the hilar structures en muss. Five patients survived, two of whom developed postoperative bronchopleural fistulas. The classical technique of individual hilar ligation was performed on three other patients undergoing trauma pneumonectomy. One patient survived and developed a bronchopleural fistula. Approaches to Rupture of the Descending Thoracic Aorta
Although it is an uncommon injury even in the busiest trauma centers, blunt rupture of the descending thoracic aorta continues to stimulate many published case reports, small and large series, multicenter studies, and new approaches to treatment. The four most significant changes over the past 10
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years were nonoperative management, delay to definitive management, use of endovascular stenting for repair, and use of the centrifugal pump for operative repair. First reported by Conn et a1,18 there have been continuous case reports or small series since that time describing nonoperative management. All patients managed in this way have had severe associated injuries in which survival or meaningful recovery was doubted at the time the injury to the thoracic aorta 28, 62, 63,87 This approach is similar to that used with nonoperative was diagn~sed.~, management of acute dissection of the thoracic aorta. The patient undergoing nonoperative management of an intimal tear or small blunt rupture of the thoracic aorta should have his or her mean arterial blood pressure maintained at the 60 to 70 mm Hg level with antihypertensive agents, such as esmolol, labetalol, or metoprolol. The length of time that antihypertensive therapy is necessary, should operation be deferred permanently, is unknown. Documentation of healing or, at least, stability of the lesion likely will be accomplished with spiral CT in the future. Similarly, delays in repair of blunt tears of the descending thoracic aorta have become more common in all trauma 63 Patients with multiple associated injuries, particularly to the brain or lungs, are the subset who benefit most from deferred repair. In patients with concomitant pulmonary contusions who are otherwise stable, a trial of operative positioning and so forth is worthwhile. If insertion of the double-lumen endotracheal tube, positioning of the patient in the right lateral decubitus position, and inflation of the occluding balloon in the left mainstem bronchus cause arterial desaturation, the operative repair should be delayed. In the recent report by Pate et al,63elective delayed operation was performed in 15 patients, whereas 11 patients never had aortic repair. As stated by the senior author, "no patient maintained on this protocol (P-blocker for heart rate greater than 90 and systolic blood pressure greater than 100 mm Hg; vasodilator if inadequate response to P-blocker), whether repaired emergently, electively, or not all, developed free rupture of the periaortic hematoma and death from traumatic rupture of the There have been preliminary reports on the use of endovascular stent grafts in the repair of blunt rupture of the descending thoracic aorta.20, 72 All seven patients reported in the references listed did well with insertion of commercially available stented grafts, with follow-up reaching 15 months in several. Longterm studies evaluating the safety of the endovascular approach are not available at this time. Operative repairs of blunt ruptures of the descending thoracic aorta using the centrifugal pump to maintain retrograde flow below the distal aortic crossclamp have been performed in the United States since 1981.61Essentially all reports to date have documented excellent results.30,34, 3638, 51, 66 Only 2 of 69 patients undergoing aortic repair with the centrifugal pump developed postoperative paraplegia in the multicenter study conducted by Fabian et al.24In the same group of patients, the mortality was 14.5%.Rates of paraplegia or mortality for the other techniques reported in the series were 010 for bypass shunt, 4.5%/ 22.7% for full bypass, 7.7%/12.8% for partial bypass, and 16.4%/15.1% for clamp and sew. One note of caution has been the report of two patients with postoperative cerebral infarcts in the posterior circulation of the brain after an aortic repair performed with use of the centrifugal pump.21Embolism from the clamp site on the left subclavian artery was blamed. The authors suggested that systemic heparinization be used when the aortic cross-clamp time exceeds 30 minutes in a patient without an associated injury to the brain.
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SUMMARY With the exception of the use of ECG to screen patients for blunt cardiac injury, recent advances in the diagnosis of thoracic trauma involve new technology. Use of surgeon-performed pericardial and pleural ultrasound for the detection of tamponade o r hemothorax, TEE or spiral CT to diagnose rupture of the thoracic aorta, and thoracoscopy to evaluate a hemothorax or the integrity of the left hemidiaphragm are all standard techniques in modern trauma centers. In terms of treatment, emergency center thoracotomy is performed more selectively and with the adjunct of staple closure for cardiac wounds. Pulmonotomy is used selectively to control deep lobar hemorrhage and to avoid the need for an emergent lobectomy. Finally, nonoperative management of an intimal tear of the thoracic aorta or delayed operative management of a full-thickness tear in the patient with multiple injuries, using P-blocker-induced relative hypotension, is rapidly becoming the standard of care thoughout the United States.
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hold technique, continuous transport, and continuous scanner rotation. Radiology 176~181-183,1990 43. Kaseda S, Aoki T, Hangai N, et al: A case of deep laceration of the lung treated with video-assisted thoracic surgical lobectomy: Case report. J Trauma 435356458, 1997 44. Kato N, Dake MD, Miller DC, et al: Traumatic thoracic aortic aneurysm: Treatment with endovascular stent grafts. Radiology 205:657-662, 1997 45. Keller KD, Shatney CH: Creatine phosphokinase-MB assays in patients with suspected myocardial contusion: Diagnostic test or test of diagnosis? J Trauma 28:58-63, 1988 46. Khoury AF, Afridi I, Quifiones MA, et al: Transesophageal echocardiography in critically ill patients: Feasibility, safety, and impact on management. Am Heart J 12713631371, 1994 47. King MR, Mucha P Jr, Seward JB, et al: Cardiac contusion: A new diagnostic approach utilizing two-dimensional echocardiography. J Trauma 23:610-614, 1983 48. Macho JR, Markison RE, Schecter WP: Cardiac stapling in the management of penetrating injuries of the heart: Rapid control of hemorrhage and decreased risk of personal contamination. J Trauma 34:711-716, 1993 49. Marts 8, Durham R, Shapiro M, et al: Computed tomography in the diagnosis of blunt thoracic injury. Am J Surg 168:688-692, 1994 50. Mayrose J, Jehle DV, Moscati R, et al: Comparison of staples versus sutures in the repair of penetrating cardiac wounds. J Trauma 46:441-444, 1999 51. McCroskey BL, Moore EE, Moore FA, Abernathy CM: A unified approach to the torn thoracic aorta. Am J Surg 162:473476, 1991 52. McGonigal MD, Schwab CW, Kauder DR, et al: Supplemental emergent chest computed tomography in the management of blunt torso trauma. J Trauma 30:1431-1435, 1990 53. Minard G, Schurr MJ, Croce MA, et al: A prospective analysis of transesophageal echocardiography in the diagnosis of traumatic disruption of the aorta. J Trauma 40:225-230, 1996 54. Mirvis SE, Shanmuganathan K, Buell J, et al: Use of spiral computed tomography for the assessment of blunt trauma patients with potential aortic injury. J Trauma 451922-930, 1998 55. Mirvis SE, Pais SO, Gens DR: Thoracic aortic rupture: Advantages of intra-arterial digital subtraction angiography. AJR 146:987-991, 1986 56. Mollod M, Felner JM: Transesophageal echocardiography in the evaluation of cardiothoracic trauma. Am Heart J 1322341-849, 1996 57. Murray JA, Demetriades D, Cornwell EE 111, et al: Penetrating left thoracoabdominal trauma: The incidence and clinical presentation of diaphragm injuries. J Trauma 433624426, 1997 58. Naughton MJ, Brissie RM, Bessey PQ, et al: Demography of penetrating cardiac trauma. Ann Surg 209:676-683, 1989 59. Newman PG, Feliciano DV Blunt cardiac injury. New Horizons 7:26-34, 1999 60. Ochsner MG, Rozycki GS, Lucente F, et al: Prospective evaluation of thoracoscopy for diagnosing diaphragmatic injury in thoracoabdominal trauma: A preliminary report. J Trauma 343704710, 1993 61. Olivier HF Jr, Maher TD, Liebler GA, et al: Use of the BioMedicus centrifugal pump in traumatic tears of the thoracic aorta. Ann Thorac Surg 38:58&592, 1984 62. Pate JW, Fabian TC, Walker W: Traumatic rupture of the aortic isthmus: An emergency? World J Surg 19:119-126, 1995 63. Pate JW, Gavant ML, Weiman DS, et al: Traumatic rupture of the aortic isthmus: Program of selective management. World J Surg 23:59-63, 1999 64. Perreault P, Soula P, Rousseau H, et al: Acute traumatic rupture of the thoracic aorta: Delayed treatment with endoluminal covered stent: A report of two cases. J Vasc Surg 27538-544, 1998 65. Poole GV, Morgan DB, Cranston PE, et al: Computed tomography in the management of blunt thoracic trauma. J Trauma 35:29&302, 1993 66. Read RA, Moore EE, Moore FA, et al: Partial left heart bypass for thoracic aorta repair: Survival without paraplegia. Arch Surg 128:74&752, 1993
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67. Rodriguez A, Shatney C: The value of technetium-99m pyrophosphate scanning in the diagnosis of myocardial contusion. Am Surg 48:472474, 1982 68. Rothstein RJ, French RS, Mena I, et al: Myocardial contusion diagnosed by first-pass radionuclide angiography. Am J Emerg Med 4:210-213, 1986 69. Rozycki GS, Ballard RB, Feliciano DV, et al: Surgeon-performed ultrasound for the assessment of truncal injuries: Lessons learned from 1540 patients. Ann Surg 228:557567, 1998 70. Rozycki GS, Feliciano DV, Ochsner MG, et al: The role of ultrasound in patients with possible penetrating cardiac wounds: A prospective, multicenter study. J Trauma 46543-552, 1999 71. Rozycki GS, Feliciano DV, Schmidt JA, et al: The role of surgeon-performed ultrasound in patients with possible cardiac wounds. Ann Surg 223:737-746, 1996 72. Semba CP, Kato N, Kee ST, et al: Acute rupture of the descending thoracic aorta: Repair with use of endovascular stent-grafts. JVIR 8:337-342, 1997 73. Shapiro MJ, Yanofsky SD, Trapp J, et al: Cardiovascular evaluation in blunt thoracic trauma using transesophageal echocardiography (TEE). J Trauma 31:835-840, 1991 74. Shoemaker WC, Carey SJ, Yao ST, et al: Hemodynamic monitoring for physiologic evaluation, diagnosis, and therapy of acute hemopericardial tamponade from penetrating wounds. J Trauma 13:3644, 1973 75. Sisley AC, Rozycki GS, Ballard RB, et al: Rapid detection of traumatic effusion using surgeon-performed ultrasonography. J Trauma 44:291-297, 1998 76. Sugg WL, Rea WJ, Ecker RR, et al: Penetrating wounds of the heart. J Thorac Cardiovasc Surg 56:531-545, 1968 77. Symbas PN, Harlaftis N, Waldo WJ: Penetrating cardiac wounds: A comparison of different therapeutic methods. Ann Surg 183:377-380, 1976 78. Tenzer ML: The spectrum of myocardial contusion: A review. J Trauma 25:62(%27, 1985 79. Trupka AW, Waydhas C, Hallfeldt KKJ, et al: Value of thoracic computed tomography in the first assessment of severely injured patients with blunt chest trauma: Results of a prospective study. J Trauma 43:405412, 1997 80. Velmahos GC, Baker C, Demetriades D, et al: Lung-sparing surgery after penetrating trauma using tractotomy, partial lobectomy, and pneumonorrhaphy. Arch Surg 134:186-189, 1999 81. Vignon ,’I Lagrange P, Boncoeur MP, et al: Routine transesophageal echocardiography for the diagnosis of aortic disruption in trauma patients without enlarged mediastinum. J Trauma 40:422427, 1996 82. Vignon P, Ostyn E, Franqois 8, et al: Limitations of transesophageal echocardiography for the diagnosis of traumatic injuries to aortic branches. J Trauma 42:960-963, 1997 83. Wagner JW, Obeid FN, Karmy-Jones RC, et al: Trauma pneumonectomy revisited: The role of simultaneously stapled pneumonectomy. J Trauma 40:590-594, 1996 84. Wall MJ Jr, Villavicencio RT, Miller CC 111, et al: Pulmonary tractotomy as an abbreviated thoracotomy technique. J Trauma 45:1015-1023, 1998 85. Weiss RL, Brier JA, OConnor W, et al: The usefulness of transesophageal echocardiography in diagnosing cardiac contusions. Chest 109:73-77, 1996 86. Weyman AE: Pericardial diseases. In Weyman AE (ed): Cross-sectional Echocardiography. Philadelphia, Lea & Febiger, 1982, pp 480491 87. Wigle RL, Moran JM: Spontaneous healing of a traumatic thoracic aortic tear: Case report. J Trauma 31:280-283, 1991 88. Williams JB, Silver DG, Laws HL: Successful management of heart rupture from blunt trauma. J Trauma 21:534-537, 1981 89. Woodring JH, King JG: Determination of normal transverse mediastinal width and mediastinal-width to chest-width (M/ C) ratio in control subjects: Implications for subjects with aortic or brachiocephalic arterial injury. J Trauma 29:1268-1272, 1989
Address reprint requests to David V. Feliciano, MD Department of Surgery Grady Memorial Hospital 69 Butler Street, SE Atlanta, GA 30303
0039-6109/99 $8.00
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ADVANCES IN THE DIAGNOSIS AND TREATMENT OF THORACIC TRAUMA David V. Feliciano, MD, and Grace S. Rozycki, MD, RDMS
ADVANCES IN THE DIAGNOSIS OF THORACIC TRAUMA Value of Admission Electrocardiogram in the Diagnosis of Blunt Cardiac Injury
Although much has been written about the clinical entity of blunt cardiac injury, there are few patients that require treatmer1t.5~Usually caused by a direct precordial blow sustained in a motor vehicle crash 80% to 90% of the time, the term blunt cardiac injury now includes an entire spectrum of injuries. Most publications describe new-onset sinus tachycardia as the most common finding on an admission electrocardiogram (ECG), but the precise pathophysiology has never been elucidated. Other reported new-onset arrhythmias include atrial fibrillation or flutter, premature ventricular contractions, and ventricular tachycardia or fibrillati~n.~~ New-onset conduction disturbances also are noted on the admission ECGs of some patients with true myocardial contusion. In addition to T-wave and STsegment abnormalities, which would be expected with a bruise to the ventricular myocardium, Tenzer's review listed first-degree heart block, right bundle-branch block, right bundle-branch block with hemiblock, and third-degree heart block as having occurred Tachyarrhythmias or conduction disturbances are the most common clinical manifestations of cardiac contusion, and the admission ECG is the most logical diagnostic tool of choice. Disparaged by the authors of studies on radioisotope and transesophageal echocardiscanning,67,68 transthoracic ech~cardiography,~~ ographyS5recent reports have repeatedly documented that the initial ECG is an
From the Department of Surgery, Emory University School of Medicine (DVF, GSR); and Department of Surgery (DVF) and Division of Trauma/Surgical Critical Care (GSR), Grady Memorial Hospital, Atlanta, Georgia
SURGICAL CLINICS OF NORTH AMERICA VOLUME 79 * NUMBER 6 * DECEMBER 1999
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excellent filter when evaluating patients with blunt thoracic trauma.8,29, 39 In the normotensive patient with absence of new-onset tachyarrhythmias or conduction disturbances on the initial ECG and during a period of in-emergency center observation, blunt cardiac injury of clinical significance is not When new-onset tachyarrhythmias or conduction disturbances, unexplained hypotension, or a history of cardiac disease are present in the victim of blunt thoracic trauma, admission and monitoring are justified. Because numerous studies have demonstrated the imprecise relationship between creatine phosphokinase myocardial band (CPK-MB), cardiac troponin T (cT,T), and cardiac troponin I (cT,I) levels, they should not be drawn in the admitted patient unless there is a question of a concomitant myocardial infarction.', 6, 27, 39, 45 Transthoracic or transesophageal echocardiography is used as an adjunct in patients with persistent ECG abnormalities or unexplained hypotension after blunt thoracic trauma.I2,73
Value of Surgeon-Performed Ultrasound in the Diagnosis of Cardiac Rupture or Perforation and Traumatic Hemothorax
At the far end of the spectrum of blunt cardiac injury are rupture at the caval-atrial junction, left atrial appendage, or right ventricular outflow 88 Similarly, one of the most lethal penetrating thoracic wounds is that involving the heart with secondary tamponade or exsanguination. By definition, patients with the larger ruptures or perforations will be dead at the scene of injury or will die in transit (approximately 60% to 80% of all patients with penetrating cardiac wounds in an urban e n ~ i r o n m e n t ) . ~ ~ In the remaining small subset of patients, early diagnosis and operative repair lead to a survival rate of 70% to 80% in experienced trauma centers.13,l9 Although much has been written about diagnostic pericardiocentesis in the emergency center in such patient^,'^, 77 the treatment of choice in patients who are hypotensive or in extremis is emergency thoracotomy with cardiorrhaphy. In patients who are normotensive or mildly hypotensive, diagnostic choices in the 1970s and 1980s included measurement of central venous pressure,74subxyphoid pericardial win do^,^ or transthoracic echocardiography by a cardiologist.86 Over the past 10 years, numerous reports have documented that echocardiography performed in the emergency center by surgeons or specialists in emergency medicine using a 3.5 MHz (1 MHz = lo6 cycles/ sec) general access transducer is In the study by Rozycki et al,71 246 the diagnostic test of choice (Fig. l).69-71 patients with penetrating thoracic wounds were evaluated by surgeon-performed ultrasound. There were 236 true-negative results and 10 true-positive results. In the latter group, the mean time (available in eight patients) from ultrasound to operation was 12.1 minutes; all survived after repair of their cardiac wounds. A follow-up study by Rozycki et aF9 in 313 patients with penetrating precordial or transthoracic wounds resulted in 289 true-negative examinations, two false-positive examinations, and 22 true-positive examinations. In the latter group, all patients survived when surgery was immediately performed by the surgeon-sonographer. Finally, Rozycki et a170 completed a multicenter study in which emergency pericardial sonograms were performed by ultrasound technicians, cardiologists, or surgeons. In a series of 261 patients with penetrating precordial or transthoracic wounds evaluated at five Level I trauma centers, 29 (11.1%)had true-positive studies and 28 survived after emergency cardiac repair. The accuracy (97.3%), specificity (96.9%), and sensitivity
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Figure 1. Cardiac tamponade detected on surgeon-performed ultrasound using a 3.5-MHZ transducer.
(100%) were equivalent to those reported in the previous study from Grady Memorial Hospital / Emory University.69 Surgeon-performed ultrasound also has been found to be useful in the detection of a post-traumatic hemothorax (Fig. 2). In the prospective study by Sisley et d75surgeon-performed ultrasound detected a hemothorax subsequently
Figure 2. Post-traumatic hemothorax detected on surgeon-performed ultrasound using a 3.5-MHz transducer.
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confirmed by output from a thoracostomy tube in 39 of 40 patients. The 97.5% sensitivity and 99.7% specificity of ultrasound were equivalent to the 92.5% sensitivity and 99.7% specificity of portable chest radiographs, whereas the ultrasound examination was significantly faster. Value of Standard CT in Diagnosis
Although there has been increasing use of standard thoracic CT as an adjunct to the routine chest radiograph in the evaluation of patients with blunt or penetrating thoracic trauma over the past 10 years, its value is 5*, 65, 79 Lesions more commonly identified on standard thoracic CT versus those diagnosed on routine chest radiographs have included hemothorax, pneumothorax, pulmonary contusions, atelectasis, and diaphragmatic injuries.49,52, 79 The detection of a subclinical presentation of any of these entities with the exception of the traumatic diaphragmatic hernia may not have a significant effect on management and, therefore, the cost of the study is a concern (see article by Mirvis elsewhere in this issue). Diagnostic Modalities Used in the Detection of Traumatic Rupture of the Thoracic Aorta
Using eight radiographic signs of mediastinal abnormality on a chest radiograph (i.e., abnormal aortic contour or size, opacification of the aortopulmonary window, depression of left mainstem bronchus, tracheal shift to the right, deviation of the nasogastric tube to the right, widening of the right paratracheal stripe, presence of an apical pleural cap, widening of the paraspinal line), Woodring and Kings9 detected abnormalities in 30 of 32 patients (94%) with subsequently proven injuries to the thoracic aorta or brachiocephalic vessels. A strongly suggestive history (i.e., motor vehicle, motorcycle, or auto-pedestrian crash greater than 40 to 45 mph, significant deceleration in a motor vehicle crash, severe broadside collision, death of another victim in the crash, presence of a shoulder harness restraint) or abnormal upright chest radiograph or one performed in the reverse Trendelenburg position for the supine patient, therefore, detects the subset of patients that needs further diagnostic screening (Fig. 3). There is now a significant amount of data on the use of transesophageal echocardiography (TEE) in detecting blunt rupture of the thoracic aorta or a brachiocephalic vessel.l0,14, 16, 46, 56, sl, In the report by Buckmaster et al,14 of 121 of 160 patients with possible blunt injury to the thoracic aorta, two-dimensional TEE with color flow Doppler examinations were equivocal in 3, positive in 14 (all confirmed), and true-negative in the remainder. In contrast, there were 1 false-positive and 4 false-negative aortograms in 148 of 160 patients in the same series. In the recent prospective study by Chirillo et a1,l6 TEE had a 93% sensitivity, 98% specificity, and 98% accuracy in detecting blunt rupture of the thoracic aorta. There are, however, obvious limitations to the use of TEE in evaluating acutely injured patients, including the following: 1. Need to consult the cardiology or anesthesiology departments to perform the study 2. Operator-dependent 3. Contraindication to esophageal intubation
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Figure 3. Rapidly expanding rupture of the descending thoracic aorta at the isthmus. Patient died shortly after transfer to the trauma center.
4. Equivocal findings 5. Less than ideal visualization of the ascending aorta behind the right mainstem bronchus, branches of the transverse arch, and the descending thoracic aorta when a pneumothorax is present'O, s2
Also, some preliminary studies in major trauma centers have shown a poor sensitivity in detecting blunt rupture of the descending thoracic aorta.53Recognizing these limitations, TEE with a biplanar or multiplanar probe still is being evaluated for its overall accuracy as compared with chest radiographs, helical CT, or conventional aortography. Spiral or helical CT has been used for less than 10 years in this This technique allows for an entire anatomic region to be scanned rapidly after intravenous injection of contrast. Several studies, summarized in Table 1, have assessed the usefulness of this technique in detecting blunt rupture of the thoracic aorta.=, 32, 54 The guidelines suggested for current use of spiral CT for patients with blunt thoracic trauma in the article by Mirvis et a154are listed as follows: 1. Abnormal chest radiograph is followed by contrast-enhanced spiral thoracic CT
Table 1. USE OF SPIRAL CT IN THE DIAGNOSIS OF BLUNT AORTIC RUPTURE Spiral CT (%)
Aortography (%)
Sensitivity Specificity Accuracy Sensitivity Specificity Accuracy
Gavant et a132 Fabian et a123 Mirvis et a P
100 100 100
81.7 83 99.7
-
86
99.7
99.4 92
-
96.3 99
-
-
-
97
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2. Absence of mediastinal hemorrhage or direct signs of aortic injury by high quality CT excludes the diagnosis of injury to the thoracic aorta 3. Direct evidence of injury to the thoracic aorta or other great vessel should be followed by aortography or thoracotomy based on the experience of the institution 4. Spiral CT evidence of hemorrhage in the anterior mediastinum or paravertebral area in the absence of signs of injury to the thoracic aorta rules out injury to this structure 5. Evidence of mediastinal hemorrhage in the area of the thoracic aorta or great vessels without direct signs of vascular injury mandates aortograPhY Standard aortography or intra-arterial digital subtraction aortography (DSA) performed through a retrograde transfemoral or transaxillary approach continues to be the standard of care that other diagnostic techniques are measured against. Most centers now use DSA, a study that can be performed in 15 to 30 minutes and that has an accuracy of 97% to 100%.22, 23* 55 The major advantage to use of these techniques, in addition to accuracy, is the ability to detect injuries in all areas of the thoracic aorta and its branches.2 The disadvantage continues to be the inevitable delay as the interventional angiography team must be contacted and return to the hospital to complete this brief study. There is a slowly emerging trend to use spiral CT as an intermediate step before thoracic DSA or even as a replacement for DSA, and it is likely that the use of DSA or conventional aortography will decrease significantly in the future. Thoracoscopy
The use of video-assisted thoracoscopy continues to increase in major trauma centers. The indications for thoracoscopy in trauma include early evacuation of a clotted hem0thorax,3~evaluation of the left hemidiaphragm after pene6o and repair of pulmonary lacerations trating left thoracoabdominal 43 In patients with a retained hemoor assistance with pulmonary l~bectomy.~~, thorax, spiking temperature, and leukocytosis, thoracoscopy under one-lung anesthesia is an ideal technique for inspection of thoracic contents and evacuation of clotted blood that might eventually lead to empyema. With penetrating wounds to the left thoracoabdomen, a small injury to the left hemidiaphragm is not detectable on physical examination and may not be visualized on an early chest radiograph. Because the consequences of missing such an injury may be severe,26thoracoscopy may be used to rule one out when the track of the missile or stab wound is suggestive. The accuracy of the video-assisted technique is excellent,6oand the high incidence of such injuries with penetrating wounds to the left thoracoabdomen (59% for gunshot wounds, 32% for stab wounds in one recent study) justifies its continued ~ s a g e . With 5 ~ the large experience with videoassisted thoracoscopic techniques in treating nontrauma pulmonary lesions, it is not surprising that such techniques also have been used to treat pulmonary laceration^.^^, 43
ADVANCES IN THE TREATMENT OF THORACIC TRAUMA Current Role of Emergency Center Thoracotomy
Following the publication of the paper by Blalock and Ravitch in 19439 advocating nonoperative treatment for cardiac tamponade, there was presum-
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ably some decrease in the number of emergency thoracotomies in urban trauma centers. The rapid proliferation of penetrating thoracic wounds in such centers over the next 10 years quickly led to a more aggressive approach using emergency center thoracotomy.' The current strong indications for emergency center thoracotomy are listed as follows25: 1. Penetrating thoracic wound with agonal state or recent cardiac arrest on arrival, deterioration or cardiac arrest after care has been started in the emergency center, or uncontrolled hemorrhage from the thoracic inlet or out of a thoracostomy tube 2. Suspected subclavian vessel injury with intrapleural exsanguination 3. Need for open cardiac massage or occlusion of the descending thoracic aorta before laparotomy in the operating room 4. Need for open cardiac massage or occlusion of the descending thoracic aorta when countershock or closed chest cardiac massage is ineffective (i.e., cardiopulmonary arrest) Relative indications would include a recent cardiac arrest and associated flail chest, multiple blunt trauma, pregnancy or an abnormality of the chest wall, or the need for fluid infusion by an intracardiac route. Strong contraindications to use of the technique include penetrating trauma with no signs of life in the field and blunt trauma with no signs of life on arrival in the emergency center.I7 The technique continues to use a left anterolateral thoracotomy at the lower edge of the male nipple when a penetrating left thoracic wound is present. When a penetrating right thoracic wound is present and the patient is agonal on arrival, a bilateral anterolateral thoracotomy is performed. If intrapleural exsanguination from a suspected injury to a subclavian vessel is believed to be present, an anterolateral thoracotomy at a higher intercostal space is appropriate. Cross-clamping of the descending thoracic aorta is, however, more difficult should the higher incision be made on the left side. This latter maneuver is performed by first lifting the posterolateral edge of the left lung out of the hemithorax. Once the mediastinal pleura over the descending thoracic aorta and vertebral bodies is visualized, it is opened with a long DeBakey aortic clamp. The descending thoracic aorta then is encircled with the surgeon's left index finger before the cross-clamp is applied. Subsequent maneuvers for cardiac massage or repair include longitudinal pericardiotomy above the left phrenic nerve, exposure of the cardiac wound or rupture, and use of fingers, staples, sutures, or balloons for control of hemorrhage. Because of the cost and low yield of emergency center thoracotomy, the technique recently has been used more selectively. The overall survival of approximately 10% is somewhat deceptive, however, because the survival in the subset of patients with penetrating cardiac wounds is significantly better. In the article by Ivatury et a1,4I 22 patients with penetrating cardiac injuries arrived in the emergency center without "detectable vital signs, cardiac activity, or spontaneous respirations." Cardiac function was restored in 16 patients (72.7%),and 8 patients (36.4%) survived without neurologic sequelae. Currently, the highest survival after emergency center thoracotomy will be in patients with tamponade from an anterior penetrating stab wound to the heart only, a short prehospital time, and some vital signs present on admission. Staple Closure of Cardiac Wounds
Repair of penetrating cardiac wounds with a standard skin stapler with 6mm staples in the emergency center or operating room was first reported by
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Macho et a148in 1993. In their retrospective review of 28 patients (with 33 cardiac wounds), control of hemorrhage with staples was achieved in 26 patients (93%). This control of hemorrhage took less than 1 minute in 20 patients and less than 2 minutes in 6 patients. The authors noted that the technique was rapidly performed, “hghly effective” in controlling hemorrhage, and avoided the risk of suturing the beating heart in a population with a known increased incidence of blood-borne viruses. The successful use of staples has been duplicated in other centers and also has been studied in a swine model. In the study by Mayrose et al?O 2-cm full-thickness ventricular wounds in swine were repaired with sutures or staples. After sacrifice of the animals and removal of 4-cm strips of myocardium oriented perpendicular to the cardiac repair, acute tensile strength was found to be similar in the sutured and stapled repairs. The availability of wide skin staplers is recommended for all emergency centers where penetrating cardiac wounds might be treated. Pulmonotomy for the Control of Bleeding from the Lung
Over the past decade, a frequently used techmque in urban trauma centers has been direct entrance into the lung to perform selective ligation of bleeding vessels5, 84 Known as pulmonotomy or pulmonary tractotomy, the technique developed for the same reasons that more selective operative approaches became popular in the management of hepatic trauma. The oversewing of the bleeding entrance and exit sites in injured lobes was effective in tamponading most injuries that required thoracotomy in the past. A small subset of patients, however, continued to bleed and eventually developed asphyxiation secondary to continuing hemorrhage back into the tracheobronchial tree. Another small subset of patients continued to bleed through the sutured entrance and exit sites and died from intrapleural hemorrhage. Pulmonotomy is performed by first placing long vascular clamps into a lobar entrance or exit site or through both simultaneously, if possible. The pulmonary parenchyma then is divided between the clamps, which are used as retractors. Selective ligation of injured vessels in the pulmonary parenchyma is performed with suture material of the surgeon’s choice. An alternative approach is to use a linear staplers0to connect the entrance and exit sites and complete the pulmonotomy. After control of hemorrhage has been achieved, the site of the pulmonotomy is reapproximated with an 0 or 2-0 continuous absorbable suture. A related approach has been the use of en bloc stapling of the pulmonary hilum when trauma pneumonectomy has been performed. In the review by Wagner et a1,s3nine patients underwent trauma pneumonectomy with a 55- or 90-mm stapler used to close the hilar structures en muss. Five patients survived, two of whom developed postoperative bronchopleural fistulas. The classical technique of individual hilar ligation was performed on three other patients undergoing trauma pneumonectomy. One patient survived and developed a bronchopleural fistula. Approaches to Rupture of the Descending Thoracic Aorta
Although it is an uncommon injury even in the busiest trauma centers, blunt rupture of the descending thoracic aorta continues to stimulate many published case reports, small and large series, multicenter studies, and new approaches to treatment. The four most significant changes over the past 10
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years were nonoperative management, delay to definitive management, use of endovascular stenting for repair, and use of the centrifugal pump for operative repair. First reported by Conn et a1,18 there have been continuous case reports or small series since that time describing nonoperative management. All patients managed in this way have had severe associated injuries in which survival or meaningful recovery was doubted at the time the injury to the thoracic aorta 28, 62, 63,87 This approach is similar to that used with nonoperative was diagn~sed.~, management of acute dissection of the thoracic aorta. The patient undergoing nonoperative management of an intimal tear or small blunt rupture of the thoracic aorta should have his or her mean arterial blood pressure maintained at the 60 to 70 mm Hg level with antihypertensive agents, such as esmolol, labetalol, or metoprolol. The length of time that antihypertensive therapy is necessary, should operation be deferred permanently, is unknown. Documentation of healing or, at least, stability of the lesion likely will be accomplished with spiral CT in the future. Similarly, delays in repair of blunt tears of the descending thoracic aorta have become more common in all trauma 63 Patients with multiple associated injuries, particularly to the brain or lungs, are the subset who benefit most from deferred repair. In patients with concomitant pulmonary contusions who are otherwise stable, a trial of operative positioning and so forth is worthwhile. If insertion of the double-lumen endotracheal tube, positioning of the patient in the right lateral decubitus position, and inflation of the occluding balloon in the left mainstem bronchus cause arterial desaturation, the operative repair should be delayed. In the recent report by Pate et al,63elective delayed operation was performed in 15 patients, whereas 11 patients never had aortic repair. As stated by the senior author, "no patient maintained on this protocol (P-blocker for heart rate greater than 90 and systolic blood pressure greater than 100 mm Hg; vasodilator if inadequate response to P-blocker), whether repaired emergently, electively, or not all, developed free rupture of the periaortic hematoma and death from traumatic rupture of the There have been preliminary reports on the use of endovascular stent grafts in the repair of blunt rupture of the descending thoracic aorta.20, 72 All seven patients reported in the references listed did well with insertion of commercially available stented grafts, with follow-up reaching 15 months in several. Longterm studies evaluating the safety of the endovascular approach are not available at this time. Operative repairs of blunt ruptures of the descending thoracic aorta using the centrifugal pump to maintain retrograde flow below the distal aortic crossclamp have been performed in the United States since 1981.61Essentially all reports to date have documented excellent results.30,34, 3638, 51, 66 Only 2 of 69 patients undergoing aortic repair with the centrifugal pump developed postoperative paraplegia in the multicenter study conducted by Fabian et al.24In the same group of patients, the mortality was 14.5%.Rates of paraplegia or mortality for the other techniques reported in the series were 010 for bypass shunt, 4.5%/ 22.7% for full bypass, 7.7%/12.8% for partial bypass, and 16.4%/15.1% for clamp and sew. One note of caution has been the report of two patients with postoperative cerebral infarcts in the posterior circulation of the brain after an aortic repair performed with use of the centrifugal pump.21Embolism from the clamp site on the left subclavian artery was blamed. The authors suggested that systemic heparinization be used when the aortic cross-clamp time exceeds 30 minutes in a patient without an associated injury to the brain.
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SUMMARY With the exception of the use of ECG to screen patients for blunt cardiac injury, recent advances in the diagnosis of thoracic trauma involve new technology. Use of surgeon-performed pericardial and pleural ultrasound for the detection of tamponade o r hemothorax, TEE or spiral CT to diagnose rupture of the thoracic aorta, and thoracoscopy to evaluate a hemothorax or the integrity of the left hemidiaphragm are all standard techniques in modern trauma centers. In terms of treatment, emergency center thoracotomy is performed more selectively and with the adjunct of staple closure for cardiac wounds. Pulmonotomy is used selectively to control deep lobar hemorrhage and to avoid the need for an emergent lobectomy. Finally, nonoperative management of an intimal tear of the thoracic aorta or delayed operative management of a full-thickness tear in the patient with multiple injuries, using P-blocker-induced relative hypotension, is rapidly becoming the standard of care thoughout the United States.
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Address reprint requests to David V. Feliciano, MD Department of Surgery Grady Memorial Hospital 69 Butler Street, SE Atlanta, GA 30303