Treatment of penetrating and perforating chest wounds

TREATMENT OF PENETRATING AND PERFORATING CHEST WOUNDS* A DISCUSSION

OF ITS COMPLICATION,

THE ORGANIZED

HEMOTHORAX

VINCENTM. IOVINE,M.D. Wasbington, D. C.

T

HE penetrating or perforating chest wound is by its very nature a wound of violence. Nowhere but under the conditions of warfare can this type of wound be studied and treated in truIy significant numbers. This Iesion as it occurs in civilian life is closely reIated to its counterpart infhcted in armed combat. Therefore, the principIes evoIved from the observation and treatment of a Iarge group of these wounds shouId be appIicabIe to their management in civiIian Iife. The statistics herein presented and the suggested modes of treatment resuh from the experience’ of a group of surgica1 teams operating in the European theater during the recent war. Chest injury mortaIity has been reduced from approximateIy 25 per cent in WorId War I to about 6 per cent in the Iast conffict. This improvement resuIts in great part from a better understanding of respiratory physioIogy and the appIication of this knowIedge to actua1 treatment. ObviousIy, improved anesthetic technics and chemotherapeutic advances pIayed an important roIe in these encouraging figures. PRINCIPLES

OF TREATMENT

Much assistance in guiding treatment of the chest casuaIty can be gained by an accurate estimate of the course of the wounding missile. The amount of damage and the organs invoIved may be indicated by such knowIedge. In the case of a retained missiIe anteroposterior and IateraI x-rays of both chest and abdomen wil1 enabIe the operator to pIot the probable wound tract and to compute the organs invoIved. The vaIue of two-position views (anteroposterior and Iateral) cannot be overemphasized in the diagnostic process of accurate wound appraisa1. The course of a perforating wound can be estimated by lining up the wound of entry with the wound of exit when proper aIIowance is made for position

of the wounded subject at the time of injury. By virtue of these studies invoIvement of the mediastinum or diaphragm may be indicated taking the case out of the simpIe chest wound category. Contrary to the situation in the abdomina1 wound when importance is attached to the interva1 between injury and operation, the significant period in the chest wound is that required to stabiIize cardiorespiratory function and reIieve anoxia. The estabIishment of an adequate airway is of prime importance in emergency treatment of the chest wound casualty. Norma1 respiratory exchange must be instituted both for the purpose of relieving anoxia and also for the proper preparation of the patient for operation if the Iatter is indicated. Anoxia, which may be the resuIt of an obstructed airway, wet lung, depressed cough reflex due to pain, etc., may contribute measurabIy to the picture of shock which these patients frequently show. Diminished bIood voIume wiI1 contribute in varying degrees to the shock state in which many of these patients are found. However, in other patients with minima1 bIood Ioss aIthough apparentIy in severe shock, marked improvement may be obtained by correcting the conditions causing anoxia. The sucking chest wound indicates a. connection between the pIeura1 cavity and the externa1 atmosphere. EarIy estabIishment of an intact thoracic cage is a basic necessity in restoring norma respiratory physioIogy. Emergency treatment can be accompIished by a simple occIusive dressing to be foIIowed Iater by indicated surgica1 repair. Hemoptysis is an indication of puImonary parenchyma1 damage. It accompanies the majority of chest wounds. The presence 01 bIood in the tracheobronchia1 tree contributes to the obstructive factors preventing normal

* From the Department of Surgery, George WashingtonUniversity School of Medicine, Washington, D. C. November,

1949

677

Iovine-Chest aeration. Its early removal, either vohrntarily by the patient’s efforts or mechanicaIIy with the operator’s assistance, is to be encouraged. Oxygen administration as a supportive measure is a vaIuabIe adjunct in assisting the patient with a chest wound over periods of diffrcuIt aeration. It is not stressed purposely in this articIe in order to emphasize the more basic principIes of re-estabIishment of norma pulmonary function. In summary the surgeon wiI1 achieve the best resuIts in a chest casuaIty by attempting to establish norma respiratory exchange with an unobstructed airway in a patient with fuIIy expanded Iungs and an intact thoracic waI1. BIood repIacement, but not overIoading of the CardiovascuIar system, is indicated when there is assurance that the shock state is not entireIy due to anoxia. PRACTICAL

APPLICATION

OF THESE

PRINCIPLES

Evaluation of Damage Inflicted. History, physica and roentgen examination wiI1 accord the examiner a means of estimating the amount of injury present in the chest wound casuaIty. Any suspicion of mediastina1 or diaphragmatic invoIvement caIIs for additiona investigation and therapy from this point onward. The presence of a retained foreign body at this point is of no concern unIess it is of an unusual size or nature. Aspiration of the Chest. The presence of bIood and air in the penetrated chest cavity is a common hnding in chest injury. BIood and air occupy space previousIy reserved for the functioning Iung. The earIy and compIete remova of blood and air is a prerequisite to reestabIishment of a fully expanded, functioning Iung. This can be accompIished by repeated and thorough thoracentesis. ConsiderabIe objection has been raised in the past to the re-expansion of the freshIy wounded Iung by aspiration of air or bIood. It has been stated that re-expansion of the wounded Iung will incite fresh bIeeding or that pneumothorax is valuable in preventing continued hemorrhage. We have not found this to be so. It was the common experience of many members of this group to examine many extensiveIy Iacerated Iungs in the course of operative procedures from two to twenty-four hours after initia1 injury. It was unusua1 to observe hemorrhage or oozing of note in this lacerated tissue. Major hemorrhage that continued or was re-initiated arose

Wounds from systemic vesseIs such as the internal mammaries or the intercostaIs and required active intervention for control. It was aIs our impression that patients with injuries to the major pulmonary vessels rareIy if ever survived long enough to reach centers for dehnitive treatment. In addition to regained puImonary function the re-expanded Iung tends to prevent the estabIishment of a massive pIeura1 infection shouId contamination be overwheIming. Thus if infection should compIicate the situation, the surgeon wouId be faced most probabIy with a smaI1 basal empyema; whereas if expansion were incompIete, he would have to dea1 with a tota empyema. FaiIure to estabIish compIete re-expansion by repeated and thorough thoracentesis aIs0 carries the threat of a chronicaNy coIIapsed and imprisoned Iung. This condition condemns the patient to impaired respiratory reserve and the prospect of a second major puImonary operation. Intercostal Nerve Block. This is a frequentIy describedZe4 and simply performed procedure which is of paramount importance in treating the chest wound patient and also in preparing him for indicated operations. Severe chest pain is a frequent compIaint of patients suffering penetrating or perforating wounds of the chest. This pain is contributory not onIy to the shock state but aIso tends to suppress the voIuntary cough reflex on which the patient reIies to rid his tracheobronchia1 tree of impeding substances. ReIief of chest pain by intercosta1 block is an important factor in breaking up the cycIe described as wet Iung.5 This procedure is more efficient in the reIief of chest pain than the administration of morphine which must be given with restraint in chest injuries. For intercostal bIock to be most effective it must be performed at Ieast two IeveIs above and beIow the area of injury. There is no contraindication to repeating intercosta1 bIocks shouId it be required for contro1 of pain. Tracheobronchial Aspiration. A Iarge amount of the products of injury to the lung parenchyma hnd their way into the tracheobronchial tree. AI1 tend to accumuIate in the tracheobronchia1 tree of an injured Iung. The condition is cumuIative and with the patient’s inabiIity to eject these substances, voluntarily norma air exchange is blocked. This condition can be corrected in two ways. A suction American

Journal

of Surgery

Iovine-Chest catheter can be introduced into the trachea in a manner previousIy described.697 The apparatus required is simple and usually avaiIabIe. The presence of a catheter between the voca1 cords and in the area of carina is of itseIf sufficiently stimuIating to initiate a cough reflex. Suction

Wounds quency of cardiac and pulmonary compIications wiI1 be higher in that group. Indications for Tboracotomy. While the average penetrating or perforating wound of the chest can be handled by conservative surgical measures, there are certain indications

TABLE I COMPARATIVE iABDOMINAL

Cases

REPLACEMENT VS.

THORACIC

TABLE

THERAPY

OPERATIVE

WOUNDS)

Average Amount of BIood Per Case

Average Amount of Plasma Per Case

Thoracotomies~,

. .

Chest wall only.. 907 Abdominal wounds. i,r ‘9 Thoracic wounds..

2,382 cc.

888 cc.

1,160 cc.

640 cc.

RECORDED

41 remove much of the obstructing dkbris and heIp to re-establish normaIIy functioning Iung tissue. This procedure may be repeated at frequent intervaIs with beneficia1 effect. In the hands of a trained operator bronchoscopy wiI1 accomplish the same effect to a greater degree. The secondary diIating effect of bronchoscopy on the tracheobronchia1 tree is of further assistance in correcting this condition. Bronchoscopy may also be repeated as required. UnIess major bIood Ioss Fluid Replacement. is immediateIy obvious, a much better evaIuation of bIood replacement in a thoracic casuaIty can be made after cardiorespiratory baIance has been attained by the emergency measures already outIined. Overloading of the circuIatory system is easiIy accompIished in the chest case by overzeaIous bIood or fluid repIacement. The traumatized Iung, which is frequentIy compressed by an accompanying hemopheumothorax, is a crippIed organ which wilI respond poorly to an increased work Ioad. TabIe I shows comparative repIacement figures in thoracic and abdomina1 casuaIties. The rate of repIacement is equaIIy important and should never be rapid except in cases of obvious major bIood Ioss or continued bIood loss. PIasma and other fluids play a Iess important roIe in repIacement therapy and probabIy shouId be reserved for Iater use in the correction of a contorted bIood picture. It may be predicted that the probIem of fluid repIacement wiI1 require more careful judgment in administration for civiIian casualties since the freNovember,

I 949

II

PROCEDURES

,I

.

INDICATIONS

:_i;;. 768

FOR

Traumatic. . . . . ? of thoraco-abdominal wound. ? of persistent bIeeding.. Injury to mediastinum.. Foreign body. Lung laceration. Bone fragments.. . BronchiaI Iistula. ? of esophageal wound.,

I

THORACOTOSI-,

I 56 I 22 36 20

1I 3 3 3 3

for thoracotomy. These indications are definite and limited. TabIe II records the number of thoracotomies performed in a group of about I ,200 chest casualties. The indications warranting thoracotomy are listed. The greatest number of cases is listed under the heading, “Traumatic Thoracotomy.” In these instances the operative procedure was actuaIIy forced on the surgeon by virtue of the size of the wound. Here the size of the wound wiI1 permit evaIuation of parenchyma1 damage, thorough poIicing of the pIeura1 cavity and remova of easiIy accessible foreign bodies in IittIe more time than is required to reconstruct the chest wall and estabIish an intact pIeural space. The traumatic thoracotomy wiI1 not be seen commonIy in civiLan life since the majority of these casuaIties were the result of wounding by high expIosive she11 fragments. If injury to mediastinal structures or perforation of the diaphragm cannot be diagnosed by ordinary measures, thoracotomy is mandatory. An untreated perforation of the esophagus or stomach wiI1 certainIy increase the morbidity if not, the mortaIity of these casualties. Continued bIeeding from systemic vessels required further and carefu1 investigation. Among the most common sources of continued

680

Iovine-Chest

Wounds traumatized bronchus. With each successive phase of inspiration there is an increase in intrapIeura1 pressure. EventuaIIy severe mediastina1 shift occurs with marked respiratory and circulatory embarrassment. This serious compIication may be diagnosed rapidly and simply by physica signs, the most TABLE

Anesthetic Ether........................... PentothaI.......................

III*

Agents

Cases 307 108

Gas-oxy-ether Novocain....................... Type of InhaIation Endotracheal. Open. Mask........................................ I, II and *Tables III, slightty been taken from “Forward Surgery Wounded.“’

FIG. I. Typical x-ray of organized hemothorax foIIowing penetrating wound of chest; she11 fragment at base of right pIeura1 cavity. Note compressed and imprisoned right Iung; narrowed intercosta1 spaces and Aattened chest cage on right.

hemorrhage were injured intercostal and internal mammary vesseIs. Foreign bodies, Iung Iacerations or bone fragments are not in themseIves indications for thoracotomy in the primary definitive treatment of the chest casuaIty. Foreign bodies, unIess of unusua1 size or composition, may be removed at a Iater date under more auspicious circumstances. Laceration of the Iung is an inevitable complication of almost every penetrating or perforating chest wound. This Iesion alone does not caII for operative interference. The abiIity of damaged lung parenchyma to repair itseIf without compIication was frequently noted by observers in this group. TypicaIIy, smaI1 periphera1 bronchia fistuIas wiI1 manifest a tendency to spontaneous cIosure providing that a re-expanded lung can be kept in cIose contact with the chest waI1. Larger defects in the major bronchia branches wilt require operative repair. Pressure Pneumotborax and Subcutaneous Emphysema. Pressure pneumothorax occurred in surprisingIy few instances in this coIIection of cases. When present it is a serious threat to respiratory stabiIity and requires immediate correction. This condition resuIts from a baIIvaIve type of action in the chest waI1 or in a

673 121

862

$6

& modified, have of the Severely

prominent being the easiIy paIpabIe trachea1 shift away from the wounded side. The immediate danger can be forestaIIed by relieving built-up pressure in the affected chest through the use of a needIe connected to a water-seal trap. This was accompIished often in the fieId by inserting an intravenous-type needle in the second interspace and connecting the needIe to a container of water below the patient’s body level by plasma tubing. This simple pIan is effective unti1 the underlying defect can be corrected. Subcutaneous emphysema is seen quite commonIy in chest wounds. Its most frequent source is the punctured pIeura1 surface. Of more serious import is the emphysema resuIt ing from esophagea1 perforation and trachea1 or major bronchia injury. These subcutaneous extravasations of air subside rapidIy after the underIying pathoIogic disorder is repaired and carry no special significance other than diagnostic. Anestbesia. The most common type of anesthesia used was gas-oxygen-ether administered by the endotrachea1 route as outIined in TabIe III. Contemplated or probabIe invasion of the pIeura1 cavity during an operative procedure demands pressure-controIIed anesthesia administered by a competent anesthetist. The use of pentotha1 or local anesthetics shouId be entireIy reserved for those cases in which there wiI1 be no question of entering the pIeural cavity. THE

ORGANIZED

HEMOTHORAX

Among the postoperative problems to be deaIt with in the chest casuaIty is the comAmerican

Journal

of Surgery

Iovine-Chest

Wounds

FIG. 3. Gross specimen of excised fibrous peel removed from viscera1 pIeura1 surface. FIG. 2. Thoracotomy for decortication; fibrous encapsulating membrane of partiaIIy decorticated Iung held in AIIis clamps; underIying normaI, shiny pleura1 surface of Iung beIow crossed clamps.

plication of organized hemothorax. The lesion is characterized by an immobile, unexpanded lung which is held captive by a thick, connective tissue membrane extending over all available visceral and parietal pleural surfaces. Usually varying amounts of old blood products are present as we11 as an unorganized clot and a shaggy detritus which is the result of reactive exudation and old hemorrhage. A typical x-ray of this condition is shown in Figure I. The exudate may be infected or it may be sterile. The obvious treatment of this complication is the prevention of its occurrence by the application of the principles already outhned for management of the original chest wound. Unfortunately, under conditions of warfare the continued active treatment of the original chest casualty was prohibited in many cases by unusual circumstances. Under civilian conditions there should be little difficulty in maintaining a compIeteIy expanded lung and a thoroughly policed pIeura1 cavity. It is conceivable that small residua1 empyemas would not be unknown under these conditions but the occurrence of organized hemothorax should not be a major problem. November,

I 949

The establishment of an organized hemothorax of major degree leaves the patient with diminished pulmonary parenchymal function. In addition gradual immobilization of the chest waI1 on the affected side increased respiratory disability. Decortication, the operation by which the encapsulating membrane or peel is removed from the pleural surface of the lung to permit its reexpansion, is not a new procedure.8,g It has been utilized most frequently since the end of the last century in assisting the obliteration of oId, chronic empyema cavities. It has been re-employed during and since the late war by many operatorslo-l3 for the correction of this lesion and related conditions. Actually there is some question concerning the functional value of decorticated Iung following varying periods of imprisonment. Investigation of this probIem is now in progress. The operation of decortication is performed most profitably three to six weeks folIowing the origina injury. It is during this period that the investing membrane is sufficiently organized to allow easy peeling but at the same time is not too adherent to cause injury to the underlying lung during the process of removal. The most important areas requiring carefu1 removal of the imprisoning membrane are the peripheries of the imprisoned lung when it is contiguous with the chest waI1, the fissures and

Iovine-Chest

Wounds

4 5 FIG. 4. High power microscopiccross-section of fibrous peel; upper right fieId showsearly phase of organization with old blood, fibrin and celI detritus. In the periphery of this area there is fibroblastic invasion; remainder of field is occupied by organized fibrous connective tissue. (X 100.) FIG. 5. Low power microscopic cross-section of the fibrous peel showing we11 devetoped bIood vessels running generaIly at right angIes to the connective tissue stroma; lower portion of field shows early organization and is apposed to the visceral pleura1 surface. Upper portion of field is aduIt connective tissue and lines the pleural space. (X 8.)

the diaphragmatic surfaces. Small central areas of this investing membrane may be found to be so intimately attached to the pleural surface that they defy safe removal. Areas of this type

FIG. 6. Postoperative x-ray of decorticated right Iung. (Figure I is preoperative x-ray.) Tube in ninth right interspace to drain smaI1 residual empyema; right Iung reexpanded and she11 fragment removed.

when not removed have not impeded fuII reexpansion of the Iung. Removal of this membrane or pee1 Ieaves

behind it a normal-appearing, shiny and expansibIe pIeural surface. (Fig. 2.) The membrane is composed of fibrous connective tissue (Fig. 3) which results from reaction of the pIeura to the retained bIood products. Organization of these products takes pIace with vascuIarity being supplied by the underIying pleura. High and Iow power microscopic sections typica of this membrane are shown in Figures 4 and 5. The presence of infection hastens the process of organization of this membrane. Infection does not contraindicate the operation of decortication. Quite frequently a Iow grade infection is present but the procedure may be carried out with little fear of serious complication, particularly with the assistance of antibiotic protection. Small basal empyemas may occur but can be handIed effectiveIy by simple drainage. Figure 6 shows a typical patient postoperativeIy who had decortication, with drainage tube at the base. Occasionally we have used the intercostal tube in the later postoperative period as an open form of drainage to complete evacuation of an obviousIy infected residual space. It is interesting to note that the markedly thickened membrane or pee1 which is also present on the parieta1 surface of the pleural cavity does not require removal. The removal of this portion of the membrane is difficult to accompIish and unnecessary as shown by follow-up x-rays of these patients. With full American

Journal

of Surgery

Iovine-Chest expansion of the lung and the return of normal respiratory exchange, the markedIy thickened parieta1 membrane thins out and within a period of six to tweIve months can scarcely be demonstrated in the chest flm. The institution of remedia1 breathing exercises earIy in the postoperative period of the decorticated patient is of extreme vaIue in re-establishing norma thoracic function. The vaIue of these exercises has been ampIy demonstrated by Edwards and Harken.14 They serve not onIy to correct thoracic cage deformities but aid in re-expanding and maintaining reexpansion of the released Iung. SUMMARY I. There has been a marked improvement in the treatment of the acute chest wound based on a better understanding of respiratory physioIogy. 2. AIthough the principIes of treatment and their application are based on experience gained under conditions of warfare, it is beIieved that they can be appIied profitabIy to the civiIian casualty. 3. The importance of estabIishing stabIe respiratory function before operation is pointed out. The methods at hand for accomplishing this stabiIization are described. 1. The implications of Auid repIacement therapy in the chest casuaIty are discussed. 5. The indications for thoracotomy in Lvounds of the chest are presented. 6. The compIication of organized hemothorax is discussed and its treatment described.

November,

I 949

Wounds

683 REFERENCES

I. Forward Surgery of the SevereIy Wounded. A History of the Activities of the 2nd Auxiliary SurgicaI Group. Vol. II. rg42-1945. 2. BETTS. REEVE, H. and LEES. WILLIAM M. Militarv thoracic surgery in the forward area. J. Tborack Surg., 15: 44, 1946. 3. FITZPATRICK,LEO J. and ADAMS, ARTHUR J. Nerve block in treatment of thoracic injuries. J. Tboracic Surg., 14: 480, 1945. 4. ROVENSTINE, E. H. and BYRD, M. R. Intercostal and paravertebra1 nerve bIock. Am. J. Surg., 46: 303, 1939. 5. BURFORD, T. H. and BURBANK, BENAJMIN. Traumatic wet Iung. J. Tboracic Surg., 14: 415, 1945. 6. HAIGHT, CAMERON. Intratracheal suction in the management of postoperative pulmonary complications. Ann. .?urg.,- 107: 218; 1938. 7. SAMSON. P. C.. BREWER. L. A. and BURBANK. B. Tracheobronchial catheter aspiration. M. Bull., U. S. Army, 227, 1946. 8. DELORME, E. Du traitement d’empyemes chromiques par Ia decortication du poumon. Dixieme Congres Francois de Cbirurgie, p. 379, 1896. 9. LILLIENTHAL, H. Empyema: exploration of the thorax with primary mobiIization of the lung. Ann. Surg., 62: 309, 1915. IO. BURFORD, T. H., PARKER, E. F. and SAMSON, P. C. Early pulmonary decortication in the treatment of post-traumatic empyema. Ann. Surg., 122: 163, 1945.

t I. SMITHY, H. G. Traumatic hemothorax. J. Tboracic Surg., 12: 338, 1943. 12. TUTTLE. W. M.. LANGSTON. H. G. and CROWLEY. R. T: Treatment of organizing hemothorax bv puJmonary decortication. J. Tboracic Surg., 16: 117, 1947. I13. SAMSON, P. C. and BURFORD, T. H. Total pulmonary decortication. J. Tboracic Surg., 16: 127, 1947.

1 14. HARKEN, D. E. Activities of a thoracic center. J. . Tboracic Surg., 15: 31, 1946. 1 LT1 ;